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Postoperative pain: Knowledge and beliefs of patients and nurses

Article  in  Journal of Clinical Nursing · January 2017


DOI: 10.1111/jocn.13714

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ORIGINAL ARTICLE

Postoperative pain: knowledge and beliefs of patients and nurses


Jacqueline FM van Dijk, Marieke J Schuurmans, Eva E Alblas, Cor J Kalkman and Albert JM
van Wijck

Aims and objectives. To describe patients’ and nurses’ knowledge and beliefs
regarding pain management. Moreover, to explore the effect of information and edu- What does this paper contribute
cation on patients’ and nurses’ knowledge and beliefs regarding pain management. to the wider global clinical
Background. In the treatment of postoperative pain, patients’ and nurses’ inade- community?
quate knowledge and erroneous beliefs may hamper the appropriate use of anal- • Reading information about pos-
gesics. sible complications of severe pain
Design. A randomised controlled trial and a cross-sectional study. after surgery, increased patients’
knowledge, but not their beliefs
Methods. In 2013, half of 760 preoperative patients were allocated to the inter-
about pain management.
vention group and received written information about the complications of post- • Nurses with additional pain edu-
operative pain. The knowledge and beliefs of 1184 nurses were studied in 2014 cation had higher knowledge and
in a cross-sectional study. All data were collected with the same questionnaires. more positive beliefs about pain
Results. In the intervention group, patients’ knowledge level was significant and pain management than
higher than in the control group, while no differences were found in beliefs. nurses without additional pain
education.
Nurses had higher knowledge and more positive beliefs towards pain
• Most patients and nurses had
management compared with both patient groups. Nurses with additional pain erroneous beliefs about addiction
education scored better than nurses without additional pain education. Nurses to opioids after surgery.
were also asked what percentage of pain scores matched their impression of the
patient’s pain, and the mean was found to be 63%.
Conclusions. Written information was effective for increasing patients’ knowl-
edge. However, it was not effective for changing beliefs about analgesics and
patients and nurses had erroneous beliefs about analgesics.
Relevance to clinical practice. It is necessary to continue to inform patients and
nurses about the need for analgesics after surgery. Such education could also
emphasise that a discrepancy between a patient’s reported pain score and the
nurse’s own assessment of the patient’s pain should prompt a discussion with the
patient about his/her pain.

Key words: medication, nurse education, pain assessment, patient teaching,


postoperative pain

Accepted for publication: 25 December 2016

Authors: Jacqueline FM van Dijk, PhD, RN, Researcher, Depart- Anesthesiologist, Department of Anesthesiology, University Medical
ment of Anesthesiology, University Medical Center Utrecht, Center Utrecht, Utrecht, The Netherlands
Utrecht; Marieke J Schuurmans, PhD, RN, Professor, Department Correspondence: Jacqueline FM van Dijk, Researcher, Department
of Nursing Science, University Medical Center Utrecht, Utrecht; of Anesthesiology, University Medical Center Utrecht, Pain Clinic,
Eva E Alblas, MSc, PhD Student, Department of Communication L02.502, PO Box 85500, 3508 GA Utrecht, The Netherlands.
Science, Radboud University Nijmegen, Nijmegen; Cor J Kalkman, Telephone: +31 887557847.
MD, PhD, Professor, Department of Anesthesiology, University E-mail: j.f.m.vandijk@umcutrecht.nl
Medical Center Utrecht, Utrecht; Albert JM van Wijck MD, PhD,

© 2017 John Wiley & Sons Ltd


3500 Journal of Clinical Nursing, 26, 3500–3510, doi: 10.1111/jocn.13714
Original article Knowledge and beliefs about pain

Therefore, nurses themselves should not be hindered by bar-


Introduction
riers preventing adequate pain treatment. According to many
Many patients experience moderate or severe pain after practice guidelines, nurses should have up-to-date knowledge
surgery. The day after surgery, pain scores of patients who and appropriate beliefs regarding pain management (Lui
had undergone different types of surgery are often high, et al. 2008) and receive regular education on pain measure-
indicated by scores >4 on the numeric rating scale (NRS; ment and pain treatment (VMS 2009).
Gerbershagen et al. 2013). A patient’s pain score on the To enhance the process of pain assessment and medica-
NRS is the leading indicator for postoperative pain treat- tion, the aim of this study was twofold. First, we measured
ment (Max et al. 1995, Gordon et al. 2005). the knowledge and beliefs about postoperative pain and
pain management in both patients and nurses. Second, we
measured the influence of written information for patients
Background
and of additional pain education for nurses on their knowl-
Previous research has shown that professionals’ interpreta- edge and beliefs about postoperative pain and pain manage-
tions of pain are not in line with the actual perceptions of ment.
patients (Van Dijk et al. 2012). Most patients consider post-
operative pain with an NRS score of 4 6 as bearable, while
Methods
acute pain nurses (APNs) consider pain with an NRS score
>4 unbearable (Van Dijk et al. 2012). In clinical practice,
Design
many patients who report NRS scores >4 refuse analgesics
offered in accordance with the guidelines for pain manage- The patient study was a randomised controlled trial (RCT)
ment. It is not known why postoperative patients give high and the nurse study was a prospective, cross-sectional
NRS scores but refuse analgesics, especially opioids. Barriers study.
such as fear of addiction and side effects, lack of knowl-
edge about the negative consequences of pain and a desire to
Participants
look tough play a role (Van Dijk et al. 2016). In addition,
if patients are in pain, it is important that they accept opioids Between 2 April–9 July 2013, all adult preoperative
when lighter analgesics are not enough to reduce the pain. patients scheduled for elective surgery at a university hospi-
Relief of pain is not only for patient comfort, but also for tal were considered for inclusion during their visit to the
prevention of complications such as a pneumonia and throm- outpatient preoperative evaluation (OPE) clinic. Patients
bosis. Specific information given prior to surgery about pain unable to understand Dutch were excluded.
and pain treatment may help postoperative patients to All nurses working with surgical patients in Dutch hospi-
achieve better pain relief. Patient education is the process of tals were recruited for the nurse study. Between 28 April–
influencing patient behaviour by making changes in attitudes, 14 August 2014, nurses working in 73 hospitals in the
knowledge and skills necessary to keep or enhance health Netherlands were asked to fill in the digital questionnaires.
(Stergiopoulou et al. 2007). In a Cochrane review, Nicolson
et al. (2009) found mixed results after using leaflets to
Ethical considerations
improve patients’ level of knowledge. Moreover, preopera-
tive patients receive more leaflets and many patients do not Both studies were approved by the Institutional Ethics
understand or remember what is written. Committee of the University Medical Center Utrecht (pro-
Not only do patients lack knowledge about analgesics and tocol 12/567 and 14/211). The RCT was registered with
the negative consequences of pain but studies have also registration number ISRCTN 12922064. Written informed
shown that nurses had a low level of knowledge as well as consent was gained from all patients. Consent of the nurses
negative attitudes towards opioid analgesia (Matthews & was implied when an individual respondent completed the
Malcolm 2007, Murnion et al. 2010). This is a concern given questionnaire.
the fact that nurses have an important function in the assess-
ment and treatment of patients’ pain. They administer pre-
Data collection
scribed analgesic drugs and often must decide on the optimal
dose and dosing interval for individual patients. When Procedure
patients refuse analgesics, nurses can challenge patients’ Patients were either preoperatively exposed to information
beliefs and attempt to change the associated behaviours. about postoperative pain and potential complications or

© 2017 John Wiley & Sons Ltd


Journal of Clinical Nursing, 26, 3500–3510 3501
JFM van Dijk et al.

not. There were no valid baseline assumptions possible Instruments


regarding the difference in knowledge and beliefs between Patients’ characteristics (e.g. gender, age, highest education
the two groups; therefore, formal power calculation was and previous surgery) and nurses’ characteristics (e.g. gen-
not feasible. Data collection of the study was planned for a der, age, level of education and years of experience) were
period of three months, including as many patients as pos- recorded. The 11 statements in the questionnaires were
sible in this period. divided into two groups: (1) knowledge and (2) beliefs
A researcher (EA) explained the purpose of the study regarding pain and pain treatment. Each statement needed
to all eligible patients at the OPE clinic while they were to be scored on a five-point Likert scale from ‘strongly dis-
waiting for their preoperative consultation and they were agree’ (1)–‘strongly agree’ (5). The Pain Knowledge Ques-
asked to participate. Questionnaires with or without tionnaire (Van Dijk et al. 2015a) and the beliefs subscale of
information were inserted in sealed opaque envelopes, the Barriers Questionnaire (BQ; McNeill et al. 1998, Dihle
shuffled and sequentially numbered. The envelopes were et al. 2008) were used. For the nurses, we added one extra
only opened when patients agreed to participate. The question about pain assessment.
researcher asked them to read the text first if they had
not done so before beginning to answer the questions. Pain Knowledge Questionnaire
To ensure this procedure, the researcher observed the The Pain Knowledge Questionnaire was used in a previous
respondent during the reading and answering. The ques- study (Van Dijk et al. 2015a). Four statements regarding
tionnaires, with or without information, were read aloud pain management were formulated based on the literature
for patients with impaired eyesight. After filling in the and expert opinion. The face validity of these statements
questionnaires, patients had usual care preoperative con- was confirmed by pain experts and experts in patient com-
sultation including general information about postopera- munication. The statements of the Pain Knowledge Ques-
tive pain management. tionnaire were as follows: ‘I am familiar with pain
For the nurse study, an email with a link to the online assessment from 0 to 10’, ‘Morphine is given only in the
questionnaire was sent to 73 APNs working in 73 hospitals final stages of cancer’, ‘If you have severe pain after sur-
in the Netherlands. The email addresses of these coordina- gery, you will have a higher risk of complications’, and
tors of acute pain services were obtained from an up-to- ‘Morphine is a strong painkiller’. Each statement needed to
date list. APNs were asked to send the accompanying email be scored on a five-point Likert scale from ‘strongly dis-
with the link to the online questionnaires to the nurses on agree’ (1)–‘strongly agree’ (5), with higher scores indicating
the surgical wards in their hospital. The email for the better knowledge. We assumed that all nurses were familiar
nurses explained the content of the study and stated that with the first statement (‘I am familiar with pain assessment
the questions concerned postoperative pain and, moreover, from 0 to 10’) and thus skipped this statement. We added
that their responses on the questionnaires were processed one question: ‘In your opinion, what percentage of NRS
anonymously. scores matches your own impression of the patient’s pain?’
The answer categories were in 11 steps, from 0–100%.
Intervention
For the patients in the intervention group, the question- Beliefs subscale of BQ
naires with information started with a short (87-word) The beliefs subscale was found valid (face validity and con-
paragraph: ‘It is possible that you will have pain after sur- tent validity) and reliable (internal consistency), and was
gery. Usually, we can treat this pain adequately. If you have used to measure the extent to which individuals had con-
severe pain, we can administer a strong analgesic, such as cerns about reporting pain and using analgesics (McNeill
morphine. If severe pain is not adequately treated, it can et al. 1998, Dihle et al. 2008). The questionnaire consists
have negative health consequences. Pain is unpleasant and of seven items that address beliefs about pain management
can cause complications. Severe pain can cause pneumonia (i.e. inability to control pain, fear of addiction, good
if it prevents you from coughing after surgery, and throm- patients avoid talking about pain, side effects, complaining
bosis can occur if it prevents you from moving normally. of pain distracts physician from treating underlying illness,
Therefore, good pain management can prevent complica- tolerance and progression of disease). The scale was trans-
tions’. This text was derived in a meeting with experts on lated into Dutch by the forward–backward translation
pain management and patient education. Patients in the method (Beaton et al. 2000). The items were rated using a
control group received the same questionnaire but without five-point Likert scale, anchored with ‘strongly disagree’
information, simply starting with the first question. (1), and ‘strongly agree’ (5).

© 2017 John Wiley & Sons Ltd


3502 Journal of Clinical Nursing, 26, 3500–3510
Original article Knowledge and beliefs about pain

55 years (range 20 88), 52 women and 35 men]. Sixty-one


Statistical analysis
patients were read the questionnaires aloud (30 in the
Descriptive statistics were used to describe the sample. intervention group and 31 in the control group). Patients
Results for continuous variables were expressed as means underwent all types of surgery (e.g. eye, orthopaedic, heart,
with standard deviations (SDs). Categorical data were brain surgery). The demographic data of each group are
expressed as frequencies and percentages. For statistical presented in Table 1.
testing for differences in means, Student’s t-test was used.
All answers on the questionnaires were rated using a five- Patients’ answers on the questionnaires
point Likert scale. Scores on each scale were added up to a Answers on the questionnaires are shown in Fig. 2. In total,
sum score; higher scores indicated higher levels of knowl- 79% of the patients were neutral or agreed with the state-
edge or stronger barriers. For the graphs, three categories ment that people become addicted to analgesics easily; 60%
were made: to make the ‘disagree’ category (‘strongly dis- were neutral or agreed with the statement that pain medica-
agree’ and ‘disagree’ combined), the ‘neutral’ category and tion should be saved in case the pain gets worse; and 37% of
the ‘agree’ category (‘strongly agree’ and ‘agree’ combined).
Table 1 Demographic data of the patients
The results were considered statistically significant if
p-values were <005. Statistical analyses were performed Intervention Control
group (n = 381) group (n = 379)
using IBM SPSS Statistics version 20.0 (IBM, New York, NY,
USA). Age mean (SD) 538 (171) 543 (169)
Gender, n (%)
Female 192 (50) 177 (47)
Results Previous surgery 327 (86) 322 (85)
yes, n (%)
Patients Education, n (%)*
Low 125 (33) 102 (27)
In total, 862 patients were asked to participate in the study. Medium 138 (36) 135 (36)
The data of 760 patients were analysed: 381 in the High 118 (31) 142 (37)
intervention group and 379 in the control group (Fig. 1). *No significant difference in education between the two groups,
Eighty-seven patients refused to participate [mean age p = 009.

Patients for clinical surgery


visiting OPE clinic (n = 862)

Excluded (n = 87)
♦ Refused to participate:
- not interested (n = 26)
- more appointments (n = 29)
- too sick (n = 7)
- no reason (n = 25)

Randomised (n = 775)

Allocated to intervention group (n = 388) Allocated to control group (n = 387)

Excluded from analysis (n = 7) Excluded from analysis (n = 8)


♦ Incomplete data ♦ Incomplete data

analysed (n = 381) analysed (n = 379)


Figure 1 Consort flow diagram of the patients.

© 2017 John Wiley & Sons Ltd


Journal of Clinical Nursing, 26, 3500–3510 3503
JFM van Dijk et al.

Knowledge
100%

80%

60%

40%

20%

0%
Contr Int Contr Int Contr Int Contr Int

I am familiar with Morphine is given If you have severe Morphine is a strong


pain assessment from only in the final pain after surgery, painkiller
0-10, where 0 is no stages of cancer* you will have a higher
pain and 10 worst risk of complications
imaginable pain

Agree Neutral Disagree


Beliefs
100%

80%

60%

40%

20%

0%
Contr Int Contr Int Contr Int Contr Int Contr Int Contr Int Contr Int

Good Pain It is easier to Pain Complaints People The


patients medicine put up with medicine of pain become experience
avoid talking should be pain than cannot could addicted to of pain is a
about pain saved in with the really distract a pain sign that the
case the side effects control pain physician medicine illness is
pain gets that come from easily getting
worse from pain treating my worse
Figure 2 Patients’ answers on the knowledge
medicine underlying
illness and beliefs questions. Contr, control group;
Int, intervention group. *This question is
Agree Neutral Disagree reversed in the total knowledge score.

the patients were neutral or agreed with the statement that


Nurses
morphine is given only in the final stages of cancer.
A significant difference in knowledge was found between In total, 28 of the 73 approached APNs working in 73 hos-
the intervention and the control groups: mean (SD) 41 pitals (38%) decided to participate in the study, and 1184
(067) and 38 (063), respectively (p < 0001). No signifi- nurses completed the questionnaire. Only 15 of the 28
cant difference were found in beliefs: mean (SD) 27 (077) APNs reported the actual number of nurses to whom they
for the intervention group and 28 (075) for the control had sent the questionnaire. Based on the data of these 15
group (p = 077). APNs, the response rate was 42%. The demographic data
Eighty-five per cent of the patients had previous surgery. are presented in Table 2.
In a post hoc subgroup analysis, a significant difference in
knowledge was found in patients who had previous surgery: Nurses’ answers on the questionnaires
mean (SD) 41 (067) for the intervention group and 38 Answers on the questionnaires are shown in Fig. 3. In total,
(064) for the control group (p < 0001). However, the dif- 51% of the nurses were neutral or agreed with the state-
ference in knowledge was not found in the group that had ment that people become addicted to analgesics easily.
not had previous surgery: mean (SD) 39 for the The mean (SD) score on the Pain Knowledge Question-
intervention group and 37 for the control group (p = 01). naire for nurses with additional pain education was 46

© 2017 John Wiley & Sons Ltd


3504 Journal of Clinical Nursing, 26, 3500–3510
Original article Knowledge and beliefs about pain

Table 2 Demographic data of the nurses increased in the intervention group compared with the con-
Age, mean (SD) 383 (121) trol group, before visiting the anaesthesiologist in the
Gender, n (%) preadmission clinic. A systematic review evaluated 19 stud-
Female 1061 (90) ies on patient education before surgery: All studies com-
Hospital, n (%)
bined written, video and face-to-face interventions.
0–700 beds 463 (39)
Knowledge was the only positive outcome. No significant
>700 beds 720 (61)
Not known 1 differences were found in concerns about taking analgesics,
Experience with surgical patients in years, mean (SD) 117 (104) patients’ analgesic intake or pain ratings after surgery
Received additional education on pain, n (%) 761 (64) (Ronco et al. 2012). In line with these studies, we found
Student nurse, n (%) 98 (8) that after giving patients specific information about the
importance of good postoperative analgesia, their knowl-
edge improved; however, their beliefs about pain treatment
(049) and for nurses without additional pain education 45 did not change. A possible explanation could be found in
(056) (p = 002). Higher scores indicated more knowledge. the difference between automatic and planned behaviour.
The mean (SD) score for the question ‘In your opinion, Automatic processes enable behaviours to be carried out
what percentage of pain scores matches your own impres- with little or no demand on cognitive effort. We must make
sion of the patient’s pain?’ was 63% (176), with 32% of the most of our automatic behaviours: otherwise, we could
the nurses (n = 378) answered 50% or less. The mean not function. These automated processes, or habits, can
scores for nurses with additional pain education and for make behavioural changes very complicated. Education can
nurses without additional pain education were 635% lead to improved knowledge; however, this does not neces-
(181) and 613% (165), respectively (p = 004). The mean sarily change old beliefs and habits (Aarts 2009). Therefore,
(SD) score for the beliefs questionnaire for nurses with patients can have increased knowledge of pain treatment
additional pain education was 19 (049) and for nurses without the desired changes in their beliefs or behaviours in
without additional pain education 20 (054) (p = 003) accepting analgesics after surgery.
Higher scores indicated stronger barriers (Table 3). Previous research with postoperative patients has
reported that patients have concerns about addiction to
pain medication and have beliefs that pain medication
Discussion
should be saved in case the pain gets worse (Watt-Watson
The present study described patients’ and nurses’ knowl- et al. 2004, Brown et al. 2013). In the present study, 79%
edge and beliefs about postoperative pain and pain manage- of the patients were neutral or agreed with the statement
ment. Moreover, we analysed the influence of written that people become addicted to analgesics easily; 60% were
information for patients and of additional pain education neutral or agreed with the statement that pain medication
for nurses on their knowledge and beliefs about postopera- should be saved in case the pain gets worse; and 37% of
tive pain and pain management. Patients’ knowledge level the patients were neutral or agreed with the statement that
was significantly higher in the intervention group than in morphine is given only in the final stages of cancer. Patient
the control group. No differences were found in beliefs. concerns about using analgesics have been cited as major
Nurses had higher knowledge levels and lower barriers contributors to the problem of inadequate pain manage-
towards pain management than patients. Nurses with addi- ment (Ward et al. 2001, Dawson et al. 2005). These con-
tional pain education had higher knowledge levels and cerns may explain the finding that despite the information
lower barriers towards pain management than nurses with- provided with the questionnaire, 50% of the patients in the
out such education. intervention group were neutral or disagreed with the state-
Few studies have examined patients’ knowledge on pain ment that severe pain after surgery will cause a higher risk
treatment after being provided with written information. of complications.
Chumbley et al. (2004) examined the effect of written In agreement with other studies (Chumbley et al. 2004,
information on patients’ knowledge of patient-controlled Brown et al. 2013), a high percentage (85%) of patients
analgesia (PCA) after surgery. Patients had higher knowl- had had surgery before. In this group, a significant differ-
edge of the use of PCA; however, it had no effect on pain ence in knowledge compared to the first-time surgery group
relief, knowledge of side effects or worries about addiction. was found. Although these patients had undergone surgery
Cheung et al. (2007) examined the effect of providing writ- before, and the pain was treated by healthcare profession-
ten information about anaesthesiology: patients’ knowledge als, their beliefs did not change, and they still had high

© 2017 John Wiley & Sons Ltd


Journal of Clinical Nursing, 26, 3500–3510 3505
JFM van Dijk et al.

Knowledge
100%

80%

60%

40%

20% Agree

0% Neutral
With Without With Without With Without Disagree
Morphine is given If you have severe Morphine is a
only in the final pain aer surgery, strong painkiller
stages of cancer* you will have a
higher risk of
complicaons

In your opinion, what percentage of pain scores matches your own


impression of the paent's pain?
30

25

20

% 15

10

0
0 10 20 30 40 50 60 70 80 90 100

Beliefs
100%

80%

60%

40%

20%

0%
Without

Without

Without

Without

Without

Without

Without
With

With

With

With

With

With
With

Good paents Pain medicine It is easier to Pain medicine Complaints of People get The
avoid talking should be put up with cannot really pain could addicted to experience of
about pain saved in case pain than with control pain distract a pain medicine pain is a sign
the pain gets the side physician from easily that the illness Figure 3 Nurses’ answers on the question-
worse effects that treang the is geng naires. With = nurses with additional pain
come from underlying worse
education, Without = nurses without addi-
pain medicine illness
tional pain education. *This question is
Agree Neutral Disagree reversed in the total knowledge score.

concerns about addiction to pain treatment. Fifty-one per education). Clearly, even today, many nurses remain con-
cent of the nurses were neutral or agreed with the same cerned about patients developing opioid addiction after sur-
statement (47% of the nurses with additional pain educa- gery. One possible reason is that nurses have learned that
tion and 57% of the nurses without additional pain chronic pain patients are at risk of opioid addiction.

© 2017 John Wiley & Sons Ltd


3506 Journal of Clinical Nursing, 26, 3500–3510
Original article Knowledge and beliefs about pain

Table 3 Means of knowledge and beliefs for patients and nurses had their own scale regarding the meaning of the NRS
scores. Moreover, patients know that nurses sometimes
Patients Nurses
doubt that their pain is truly severe, and patients said it
Intervention Control With pain Without pain hurt their feelings when they were not taken seriously (Van
group group education education
Dijk et al. 2016).
Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Several studies showed that many patients suffered from
Knowledge 41 (067) 38 (063) 46 (049) 45 (056) severe postoperative pain (Dolin et al. 2002, Apfelbaum
Beliefs 27 (077) 28 (075) 19 (049) 20 (054)
et al. 2003). Nurses did not always seem to prioritise pain
management and, compared with other activities, treatment
However, a systematic review of long-term opioid use in of pain may actually be seen as less important (Manias
chronic pain patients revealed a low rate of opioid addic- et al. 2005). The most common barrier to adequate pain
tion (7 of 4884 patients, 014%) (Noble et al. 2010). management was the lack of time and increased workload
Moreover, the risk of addiction to opioids was lower in (Schafheutle et al. 2001, Manias et al. 2005). Deficiency in
acute pain patients than chronic pain patients, because knowledge about pain management was also an important
acute pain patients were administered opioids for a very barrier to effective pain management (Simpson et al. 2002,
short period of time after surgery (Strassels 2008). Schafer Puntillo 2003). Educating nurses was not always equally
states that the information a person has about an object effective. Some studies showed that education in pain man-
will influence the attitude that person holds about that agement can increase knowledge without changing attitude
object. Existing nurses’ negative beliefs towards opioids (Twycross 2002, Goodrich 2006). Other research showed
may be supported by misinformation and can be changed both an increased knowledge and improved attitude
by education (Schafer & Tait 1986).Therefore, this impor- towards pain management (Simpson et al. 2002). Most
tant issue should be emphasised in the additional pain edu- research has been performed with traditional teaching
cation for nurses. methods. However, traditional teaching could benefit from
Nurses often disagree with patients’ pain scores and being combined with E-learning and problem-based learn-
appear to make their own assessments of patients’ pain ing where case histories could be used (Keyte & Richardson
(Schafheutle et al. 2001, Watt-Watson et al. 2001) In the 2011). More research is needed to examine the effect of
present study, we asked nurses what percentage of pain these ways of educating nurses.
scores matched their impression of the patient’s pain and Not only time and priority are issues. Several studies
found the mean to be 63%. In other words, only 63% of showed that nurses underestimate severe pain (Adamsen &
patients’ pain scores matched the nurses’ impression of the Tewes 2000, Klopfenstein et al. 2000, Ene et al. 2008).
patient’s pain. Moreover, 378 nurses (32%) answered that Some patients depend too much on nurses for administra-
the patient’s pain score and their own impression con- tion of analgesics and many of them could take care of
curred in only 50% or less of cases. Such diverging opin- their own administration of analgesics after surgery. There-
ions on the current severity of pain are another important fore, we advocate that patients may have analgesics under
barrier to adequate pain treatment. Discrepancies between their own management as much as possible.
nurses’ assessments of pain and patients’ experiences have The patient study is strengthened by the fact that we con-
been identified, with nurses giving consistently lower rat- firmed that all patients in the intervention group had actu-
ings than patients (Sloman et al. 2005, Gunningberg & ally read the extra pain information paragraph. A potential
Idvall 2007). One possible reason for the discrepancy limitation is that we did not test the extent to which
between a patient’s pain score and the nurse’s view is that patients had retained the information until the day of sur-
patients may be confused or have delirium after surgery. gery and the postoperative period. Moreover, we did not
Another possibility is that many patients will consider NRS study the actual behaviour after surgery. It is likely that
scores between 4–6 to represent ‘bearable’ pain, not requir- some of the information will have been lost, especially if
ing additional analgesics (Van Dijk et al. 2015b), while there had been a long period between the preoperative
nurses have been taught that only NRS scores <4 may be clinic visit and the day of admission. Repeated exposure to
considered as representing bearable pain. Therefore, nurses this information (e.g. preoperatively during admission)
may be tempted to think that their patients do not under- might be necessary for maximum effect. The nurse study is
stand the NRS, and thus assign lower scores to patients’ strengthened by the fact that a large number of nurses
pain. In a previous study, we found that most patients working on postoperative surgical wards completed the
understand NRS scores very well; some patients said they questionnaire. A potential limitation is the response rate of

© 2017 John Wiley & Sons Ltd


Journal of Clinical Nursing, 26, 3500–3510 3507
JFM van Dijk et al.

38% among nurses whose APNs had forwarded the ques- role models, E-learning and exercising with case histories.
tionnaires, which may indicate a bias. That is, nurses with In such education, exaggerated concerns about possible opi-
a high level of knowledge and beliefs about pain and pain oid addiction should be addressed. Finally, patient-reported
management could be more inclined to participate than pain scores often do not match nurses’ impressions of the
nurses with a lower level. This means that the present patient’s current pain state. Nurses should be taught about
results might give a more positive impression of nurses’ the existence of and reasons for these discrepancies and be
knowledge and beliefs than would be found in actual clini- encouraged to see them as important opportunities to talk
cal practice. Another limitation might be that it was not with their patients about their pain and jointly decide on
possible to randomise nurses for the additional education; the most appropriate analgesic strategy.
the data were analysed retrospectively.

Acknowledgements
Conclusion
We thank Margaret Nicholls and Heleen van Koeven for
We provided patients with written information about the their forward backward translation of the BQ.
importance of good postoperative analgesia and accepting
analgesics to reduce the incidence of postoperative compli-
Disclosure
cations. Compared to the control group, knowledge of pain
treatment was higher in patients in the intervention group. The authors have confirmed that all authors meet the
However, the intervention did not alter beliefs regarding ICMJE criteria for authorship credit (www.icmje.org/ethica
analgesics; most patients had persistent concerns about opi- l_1author.html), as follows: (1) substantial contributions to
oids. In postoperative pain management, nurses are conception and design of, or acquisition of data or analysis
expected to alter these concerns. Nurses had high knowl- and interpretation of data, (2) drafting the article or revis-
edge scores and low barriers towards pain management. ing it critically for important intellectual content and (3)
However, more than half of the nurses were neutral or final approval of the version to be published.
agreed with the statement that postoperative patients
become addicted to pain medicine easily. There was a small
Funding
but statistically significant difference in this regard between
nurses who had received additional pain education and Financial support was provided by Astellas Pharma B.V.
nurses who had not (57% vs. 47%). Therefore, additional for the data collection of the study and by departmental
pain education appears to increase nurses’ knowledge. sources.

Relevance to clinical practice Conflict of interest


Changing nurses’ beliefs is difficult and can probably only The authors report no conflict of interest.
take place over time through a programme of continuous
education or a combination of education and appropriate

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