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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.
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,
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)
Knowledge
100%
80%
60%
40%
20%
0%
Contr Int Contr Int Contr Int Contr Int
80%
60%
40%
20%
0%
Contr Int Contr Int Contr Int Contr Int Contr Int Contr Int Contr Int
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
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
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.
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
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.
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