The clinical utility of patients’ self-rated postoperative pain after major surgery– the perspective of healthcare

professionals’

Doctoral Thesis

Lotta Wikström

Jönköping UniversitySchool of Health and WelfareDissertation Series No. 081 • 2017

Doctoral Thesis in Health and Care Sciences

The clinical utility of patients’ self-rated postoperative pain after major surgery– the perspective of healthcare professionals’Dissertation Series No. 081

© 2017 Lotta Wikström

Published bySchool of Health and Welfare, Jönköping UniversityP.O. Box 1026SE-551 11 JönköpingTel. +46 36 10 10 00www.ju.se

Printed by Ineko AB 2017

ISSN 1654-3602ISBN 978-91-85835-80-5

Abstract

Patients’ pain intensity is the most clinically relevant pain dimension to

monitor after major surgery, and assessments should, when cognition allows,

be based on self-reports. The Numeric Rating Scale (NRS) is suitable in

postoperative settings, yet, the implementation has shown varying results.

Since research on the utility of pain scales is limited, knowledge based on

healthcare professionals’ experiences is needed. Therefore, the aim of this

thesis was to describe the clinical utility of patients’ self-rated postoperativ e

pain after major surgery from the perspective of healthcare professionals. .

The thesis is based on qualitative and quantitative methods. The aims of the

qualitative studies were to describe how healthcare professionals perceive

the use of pain scales in postoperative care (I) and, through considering

critical incidents, to describe care experiences and actions taken by

healthcare professionals when assessing postoperative pain (II). The

participants in studies I (n=25) and II (n=24) were enrolled and registered

nurses and physicians with clinical experience of pain scales in postoperative

care. The aims of the quantitative studies were to determine the clinical

applicability of NRS mode- and maximum- measures (III), and NRS mode-

and median measures at rest and during activity (IV), when to describe

patients’ postoperative pain on the first day after major surgery. A further

aim was to determine the number of NRS ratings needed for the calculation

of these measures (IV). The number of surgical and orthopaedic patients

who completed study III was: n=157 and for study IV: n=479.

Studies I and II confirmed earlier findings of patients’ self-reported pain

scores as a facilitator in the understanding of pain. Organizational routines,

documentation devices, knowledge, clinical competence, continuity in care,

collaborative actions, time, and individual habits were healthcare-related

factors affecting the use of pain scales (I, II). Patient-related factors such as

patients’ ability and willingness to communicate pain were facilitators, while

disability, unwillingness to communicate or inconsistency in verbal

communication with observed behaviours were barriers (II). Multi-

dimensional communication approaches could bridge the patient-related

barriers (I, II).

Studies III and IV showed acceptable reliability for the mode and median

measures, based on daily calculations of patients’ self-rated pain scores at

rest and during activity. Rank correlations for individual mode and median

scores, based on four ratings, versus patients’ retrospective self-rated

average pain, were moderate and strengthened with increased numbers of

ratings. The Svensson method showed an individual variation within the

expected outcome and a significant systematic group change towards a

higher level of reported retrospective pain. The calculated pain measures,

particularly concerning pain at rest, were generally lower than patients’

recall of pain.

In conclusion, the findings support earlier described beneficial effects of

patients’ self-reported pain; however, present healthcare did not support the

structured utilization of pain scales. The simple measurement characteristics

of the NRS average pain measures suggest that patients’ pain can be

followed until resolved. The measures could additionally become important

patient-reported outcome measures and thus constitute new motivators to

increase the utilization of pain scales.

Original studies

The thesis is based on the following studies, which are referred to by their

Roman numerals in the text:

Study I

Wikström, L., Eriksson, K., Årestedt, K., Fridlund, B., & Broström, A.

(2014). Healthcare Professionals’ perceptions of the use of pain scales in

postoperative pain assessments. Applied Nursing Research, 27, 53-58. doi:

10.1016/j.apnr.2013.11.001. Epub 2013 Nov 12.

Study II

Wikström, L., Eriksson, K., Fridlund, B., Årestedt, K., & Broström, A.

(2016). Healthcare professionals’ descriptions of care experiences and

actions when assessing for postoperative pain– A Critical Incident

Technique Analysis. Scandinavian Journal of Caring Sciences, 30(4), 802-

812. doi: 10.1111/scs.12308. Epub 2015 Dec 28.

Study III

Eriksson, K., Wikström, L., Lindblad-Fridh, M., & Broström, A. (2013).

Using mode and maximum values from the Numeric Rating Scale when

evaluating postoperative pain management and recovery. Journal of Clinical

Nursing, 22(5-6), 638–647.

Study IV

Wikström, L., Eriksson, K., Fridlund, B., Nilsson, M., Årestedt, K., &

Broström A. (2017). The clinical applicability of a daily summary of

patients’ self-reported post-operative pain - a repeated measure analysis.

Journal of Clinical Nursing, doi: 10.1111/jocn.13818. [Epub ahead of

print]

The articles have been reprinted with the permission of the respective

journals.

Author contributions

All authors have been continuously involved throughout the process of

analysis in studies I-IV, and have contributed to the interpretation of data

and intellectual content. Lotta Wikström had the main responsibility in

studies I, II and IV. In study III the main responsibility was equally shared

with Kerstin Eriksson.

Contents

Preface ................................................................................................ 6

Introduction ......................................................................................... 7

Pain dimensions ............................................................................. 9

Prevalence of postoperative pain .............................................. 10

Pain assessment .......................................................................... 12

Measurement of postoperative pain .......................................... 14

Documentation of postoperative pain ....................................... 15

Healthcare professionals’ roles in pain management ............ 16

Rationale ........................................................................................... 19

Conceptual framework .................................................................... 21

Care routines ................................................................................ 21

Communication ............................................................................. 22

Methods ............................................................................................. 24

Design ............................................................................................ 24

Setting ............................................................................................ 25

Participants ................................................................................... 25

Data collection .............................................................................. 27

Data analysis ................................................................................ 31

Quantitative methods ................................................................... 33

Ethical considerations ..................................................................... 35

Results ............................................................................................... 37

Perceptions of the utility of pain scales (I) ............................... 37

Care experiences when assessing pain (II) ............................. 39

Care actions when assessing pain (II) ...................................... 40

Prevalence of pain (III, IV) .......................................................... 41

The clinical applicability of daily summarized measures based

on patients’ self-reported pain (III, IV) ...................................... 43

Discussion ......................................................................................... 47

Methodological aspects .............................................................. 47

Aspects of the results .................................................................. 51

Theoretical reflection ....................................................................... 58

Conclusions and clinical implications ........................................... 62

Future research ................................................................................ 65

Summary in Swedish ...................................................................... 66

Acknowledgements ......................................................................... 70

Referenses ....................................................................................... 72

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Preface

In my role as an acute pain nurse in an “Acute Pain Service Team”, I have a

pre-understanding of the area studied in this thesis. The reason I faced the

challenge of researching this area was my experienced difficulties implementing

a structured use of patients’ self-rated pain scores in surgical wards. Healthcare

professionals’, enrolled and registered nurses’ and physicians’ quality of

assessments and documentation of pain varied widely, which consequently

affected the understanding of patients’ pain. Despite the broad international and

national clinical experience of the most common one-dimensional pain scales,

their use was questioned. My clinical experience raised questions about finding

reasons for why the assessment with pain scales was not attractive to everyone.

What are the key ingredients in the assessment situation? Do healthcare

professionals perceive that the pain scales contribute to the understanding of

patients’ pain?

In the development of the scientific field of nursing, nurses have been inspired

by several scientific approaches. I have been “brought up” with the Nordic

tradition of caring science that is based on issues on life and human existence.

The human being is seen as an entity, and in the art and act of caring,

relationships and dialogues are central. Caring to me means to identify patients’

problems, needs and desires, and listening to and respecting the patient’s

perspective. Philosophies of positivism, post-positivism, interpreting and

critical and social constructivism have contributed to the multi-faceted research

questions within Nordic caring research. The understanding of the danger of

treating perceptions of the social world as objective, and neglecting subjective

interpretations and corresponding context is the background to why nurse

researchers often approach questions with various varying philosophical

perspectives. The thesis has a clinical perspective; healthcare professionals’

perceptions, experiences and actions in pain assessment situations were

explored and an approach aiming to optimize clinical use of patients’ self-rated

pain was determined. The results will hopefully contribute to better utilization

of pain scales in postoperative care.

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Introduction

The prevalence of postoperative moderate to severe pain during the first days

after major surgery is high (Fletcher, Fermian, Mardaye, & Aegerter, 2008;

Gerbershagen, Aduckathil, van Wijck, Peelen, Kalkman, & Meissner, 2013).

Awareness has increased that patients are continuously at risk of suffering from

pain in the short-term perspective, and also risk developing long-term post-

surgical health-related consequences (Liu & Wu, 2007; Althaus, Arránz,

Becker, & Neugebauer, 2014). Therefore, acute pain services (Duncan, Day,

Haigh, Gill, Nightingale, & NIPPS Group et al., 2014) and pain management

programs have been developed (Larsen, Hansen, Söballe, & Kehlet , 2010;

Spanjersberg, Reurings, Keus, & van Laarhoven, 2011). The rapid changes in

recent years that have allowed shorter hospital stays (Larsen et al., 2010;

Spanjersberg et al., 2011) however mean less time to get to know patients’

postoperative needs.

The assessment of postoperative pain is described as complex. The perception

of pain is regarded as a multi-dimensional, personal and unique experience,

related to tissue damage but also to human values as well as health status

(Armstrong, 2003; Wolrich, Poots, Kuehler, Rice, Rahman, & Bantel, 2014;

Kvachadze, Tsagareli, & Dumbadze, 2015). Additionally, the perception of pain

varies according to the present situation (Armstrong, 2003). Therefore, a

systematic assessment process of pain is described as essential to achieve the

goals of pain relief (Gordon et al., 2005; Radnovich, Chapman, Gudin, Panchal,

Webster, & Pergolizzi, 2014). Pain intensity has so far been considered to be

the most clinically relevant dimension of the pain experience to monitor,

regardless of the nature of pain. (Hjermstad et al., 2011).

The idea to promote the patient as an active participant in the assessment

procedure started in the late 40s when Keele (1948) asked patients to rate their

pain intensity on a one-dimensional verbal scale. Several decades later, the NRS

has become one of the recommended scales for most settings (Hjermstad et al.,

2011). However, the implementation of pain scales in postoperative care has

shown varying degrees of success (Gunningberg & Idvall, 2007; Ene, Nordberg,

Gaston Johansson, & Sjöström, 2008; Gordon et al., 2008). How healthcare

professionals assess patients’ pain experiences has mainly been explored by

nurse researchers (Manias, Bucknall, & Botti, 2004; Schafheutle, Cantrill, &

Noyce, 2004; Kim, Sjöström, & Schwartz-Barcott, 2006; Harper, Ersser, &

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Gobbi, 2007; Lauzon-Clabo, 2007; Rejeh, Ahmani, Mohammadi, Anoosheh, &

Kazemnejad, 2008). This could be explained by the fact that nurses have the

main responsibility for pain management after surgery (Hartog, Rothaug,

Goettermann, Zimmer, & Meissner, 2010); however, research revealed different

attitudes and assessing behaviours (Manias et al., 2004; Schafheutle et al., 2004;

Kim et al., 2006; Layman Young, Horton, & Davidhizar, 2006; Harper et al.,

2007; Lauzon-Clabo, 2007; Rejeh et al., 2008). Layman Young et al. (2006)

found predominantly positive attitudes towards pain scales, while findings from

nurses’ behaviours revealed that pain scales were seldom used (Manias et al.,

2004; Gunningberg & Idvall, 2007; Ene et al., 2008).

Evidence indicate that an attentive approach from healthcare professionals

towards patients’ pain (Dihle, Bjølseth, & Helseth, 2006; Hartog et al., 2010)

and well-functioning communication between patients and healthcare

professionals (Schwenkglenks et al., 2014) and between different healthcare

professionals are strongly related to quality of care (Havens, Vasey, Gittell, &

Lin, 2010). This knowledge has raised issues about the pain scales’ contribution

to identifying and understanding patients’ pain. Since research on the utility of

pain scales is limited, more knowledge based on healthcare professionals’

experiences of caring for patients in postoperative care is needed.

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Background

Pain dimensions

The well-known definitions of pain have set the norms of how pain should be

looked upon in healthcare. Mc Caffery (1968) revolutionized the field of pain

by her statement that “pain is whatever the experiencing person says it is,

existing whenever the person say it does”. The still prevailing definition of pain

from 1986 describes this symptom as “an unpleasant sensory and emotional

experience associated with actual or potential tissue damage, or described in

terms of such damage” (International Association for the Study of Pain [IASP],

1986). To include people who are not able to communicate verbally,

Kaasalainen (2007) added non-verbal communication of pain to her definition

of pain: “pain is an unpleasant subjective experience that can be communicated

to others either through self-report when possible or through a set of pain-

related behaviours”. Acute pain, equivalent to postoperative pain, is

additionally described as “the normal predicted physiological response to an

adverse chemical, thermal or mechanical stimulus associated with surgery,

trauma and acute illness” (Carr & Goudas, 1999). In summary, the definitions

have increased the awareness of the importance of listening to patients in pain,

believing their descriptions and accepting their pain-related behaviours.

The overall perception of postoperative pain has been described as associated

with the extent of tissue damage as well as disease characteristics such as

severity of illness (Armstrong, 2003) and preoperative chronic pain conditions

(Wolrich et al., 2014). Furthermore, the outcome of a pain experience, mainly

studied in the context of cancer, is related to the individual’s perception of the

meaning, which is believed to be a synthesis of pain occurrence, and the

perceptions of intensity and distress (Armstrong, 2003). Additionally, the

perception of pain includes the presence of other symptoms such as nausea and

tiredness (Armstrong, 2003) often occurring during the postoperative period

(Allvin, Ehnfors, Rawal, & Idvall, 2008). The emotional experience of a

symptom, including feelings of vulnerability and sadness, is defined as distress.

However, the association between distress pain occurrence and pain intensity

shows contradictory results (Goodell et al., 2005; Falk et al., 2016). In the

postoperative context, coping, expectations (Khan, Devereaux, Le Manach, &

Busse, 2016), anxiety and pain catastrophizing (Theunissen, Peters, Bruce,

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Gramke, & Marcus, 2012) are found to affect perceptions of pain and rates of

chronic post-surgery pain conditions.

The differences in overall pain perception due to ethnicity have not been

determined but available research explains ethnical group differences as being

influenced by biological, social, cultural and psychological factors (Kvachadze

et al., 2015). Also, the gender perspective has been focused upon in recent

years. Experimental and clinical findings demonstrate that women may have a

greater pain sensitivity than men, which means that they may experience more

pain than men (Kvachadze et al., 2015). Furthermore, the findings of Chapman,

Davis, Donaldson, Naylor, & Winchester, (2011,a) suggests that younger

patients experience more pain initially, but their pain resolves more quickly.

Factors influencing patients’ postoperative pain experience are presented in

Figure 1.

Figure 1. Factors that influence the understanding of patients’ postoperative pain

experience, inspired by Radnovich et al. (2014)

Prevalence of postoperative pain

Reported proportions of patients with moderate to severe pain soon after general

surgery varies; 41% (Sommer, de Rijke, van Kleef, Kessels, Peters, & Marcus,

Factors influencing patients’ postoperative pain experience

Age

Sex Previous

chronic

pain

Previous

opioid

exposure

Expectations Anxiety

Depression

Distress

Pain-

catastro-

phizing

Comorbid

conditions

Unwanted

side-effects

Social,

religious,

existential

and cultural

beliefs

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2008) and 56% (Forsberg, Vikman,, Wälivaara, & Engström, 2015) while the

reported proportion of patients with moderate to severe pain after orthopaedic

surgery is higher, 75% (Forsberg et al., 2015). Consequently, the prevalence of

chronic post-surgical pain is less for patients who has undergone general

surgery, 8-17% than orthopaedic surgery, 13-27% (Fletcher et al., 2015).

Pain is generally expected to last up to ten days after surgery (Chapman et al.,

2011 a); however, the postoperative pain trajectory is not the same for all

patients. Orthopaedic joint replacements can cause pain many weeks after

surgery (Andersen, Gaarn-Larsen, Kristensen, Husted, Otte, & Kehlet, 2009).

Pain decreases for most patients, but up to 25% of the patients are shown to

experience the same or worse pain six days after surgery (Chapman et al.,

2011a). Multimodal analgesic techniques and non-pharmacological

interventions (Table 1) are used to prevent and quickly reduce pain, preferably

tailored to the specific surgery, individual clinical factors, and patient

preferences (Chou et al., 2016). The aims are, in addition to pain reduction, to

avoid associated side effects such as bladder and bowel dysfunction, ventilator

depression (Chou et al., 2016) and long-term health-related problems such as

chronic pain (Liu & Wu, 2007; Althaus et al., 2014). The prevailing definition

of postoperative chronic pain, “pain that develops after surgery and lasts for at

least two months” (Macrae 2001) is often referred to, but considered vague.

When evaluating postoperative pain Liu & Wu (2007) suggest adding patient-

reported outcome aspects such as recovery, quality of life and satisfaction.

Patients’ preoperative pain, surgical techniques, pre-emptive and postoperative

pain management as well as patients’ psychosocial situation have been found to

be associated with the development of postoperative chronic pain conditions

(Kehlet, Jensen, & Woolf, 2006). However, patients with preoperative chronic

pain normally have prolonged pain trajectories (Chapman et al., 2011a).

Additionally, patients with preoperative opioid pharmacy are at risk of higher

postoperative pain than the population with no opioid pharmacy (Chapman,

Davis, Donaldson, Naylor, & Winchester, 2011b).

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Table 1. Postoperative pain management that may be encountered in a multi-modal

perioperative pain management regimen after major surgery

Treatment that may be encountered in a multi-modal perioperative pain management regimen at major surgery

Analgesia and analgesic techniques paracetamol/acetaminophen

NSAIDs/celecoxib

tissue/nerve blockage

opioids

clonidine

ketamine

gabapentin

Non-pharmacological interventions TENS

cooling

warmth

music

distraction

Pain assessment

Effective postoperative pain management as a result of surgical-specific

guidelines and attention to patients’ pain facilitates a comfortable recovery that

promotes rapid discharge from hospital (Larsen et al., 2010; Spanjersberg et al.,

2011). A systematic assessment process where the patients get involved as an

active participant is described as essential to achieving pain relief and to

experiencing minimal side effects from analgesia (Gordon et al., 2005). The

process of assessing postoperative pain means to identify, recognize, describe,

document and follow pain, also to select interventions, and evaluate the

individual’s response to treatment i.e. comfort and functioning, along with vital

parameters associated with the chosen treatment (Gordon et al., 2005; Swedish

Society of Anaesthesia and Intensive care [SFAI], 2010). Patients’ levels of

self-reported pain at rest and during activity are considered important

parameters in the assessment of postoperative pain (Figure 2). However,

verbally communicating patients should also be asked about their pain history.

Age, sex, psychosocial features, and comorbid conditions (Figure 1) are

additional important features to consider since patients’ self-ratings from one-

dimensional pain scales alone cannot be used as the basis for treatment

algorithms (Radnovich et al., 2014). Furthermore, when pain is unexpectedly

high, the necessary exclusion of surgical-related complications means that pain

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qualities, locality, pain at rest and during activity, and pain duration in relation

to given analgesia are relevant factors to consider (Radnovich et al., 2014).

Figure 2. Dynamic features of pain that are taken into consideration when determining

pain relieving actions, inspired by Radnovich et al., (2014)

Nurses’ course of actions when assessing patients’ postoperative pain were

found by Kim et al. (2006) to include three different strategies, namely

considering what the patient says (identifying the presence and severity of

pain), how the patient looks (the corresponding individual expressions and pain

experiences), and “how it usually is”, (the identification and validation of

possible causes of pain). The findings of Lauzon-Clabo (2007) showed a similar

pattern, illustrated in Figure 3. However, in observational studies, the most

commonly identified assessment course of action was to ask simple questions

such as: How are you? Do you need any pain killers? (Manias et al., 2004;

Schafheutle et al., 2004). Pain was rarely assessed in terms of intensity, location

or duration (Manias et al., 2004; Schafheutle et al., 2004). Therefore, it is

argued that good quality patient-reported outcome measures, i.e. patients’ self-

rated pain, are important in the prevention of post-surgery complications

(Meissner et al., 2015).

Accurate pain assessments are also important for those who cannot describe

their pain due to cognitive impairments (Hadjistavropoulos et al., 2014). In

general, healthcare professionals’ assessments of patients’ behaviours are found

Dynamic features of postoperative pain

Location Intensity

rest,

activity

Effect

on

function

Duration

Temporal

pattern

Quality

Effects of

treatment

Rate of

resolution

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assessments are compared (Ruben, van Osch, & Blanch-Hartigan, 2015). may decrease when patients experience high

levels of pain, when patients are old, and when cognitive impairments are present, which means that patients with high pain levels and patients who cannot express pain are vulnerable (Ruben et al., 2015).

postoperative pain according to Lauzon-Clabo (2007) with the addition of Kim et al. (2006)

Measurement of postoperative pain

together with the other four vital signs (blood pressure, temperature, pulse rate and respiratory rate), which were already routinely assessed (Mc Caffrey, 1997;

•What the patient says •Clients' narrative

Pain is an individual experience

•How the patient looks •Evident criteria

Clients in pain exhibit expected behavours

•How it usually is •Reference typology

A client's pain experience has a well

defined trajectory based on the surgical procedure, age and

gender

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intensity have come to include screening for pain with a one-dimensional scale

followed by a more thorough assessment (Lynch, 2001) (Figure 3). The

American Pain Society [APS], (1995) pain quality indicators of worst and

average NRS score derives from the multi-dimensional pain instrument of Brief

Pain Inventory, originally developed for the assessment of chronic pain

conditions (Daut, Ceeland, & Flanery, 1983). Psychometric tests of the one-

dimensional NRS (0 = no pain, 10 = worst possible pain) have been repeated

over the years and have shown robust validity and reliability for measuring pain

intensity (Hjermstad et al., 2011). Because of its feasibility in many settings the

NRS is now one of the dominant pain scales in clinical use. The NRS has also

been shown to work well with older patients (Hjermstad et al., 2011).

The evidence of patients’ varying interpretations of pain scales is growing

(Farrar, Pritchett, Robinson, Prakash, & Chapell, 2010; Eriksson, Årestedt,

Fridlund, & Broström, 2017; Wolrich et al., 2014; van Dijk, Kappen,

Schuurmans, & van Wijck, 2015). Scoring is suggested to be based on life

experience, interpretation of end-point descriptions, and anticipated

consequences (Farrar et al., 2010; van Dijk, Vervoort, van Wijck, Kalkman, &

Schuurmans, 2016). Therefore, strict adherence to various NRS cut-off goals

has been questioned due to the risks of opioid-related serious adverse effects

(Gordon et al., 2005). Although research was limited, Farrar et al.’s (2010)

findings indicate that the actual change between two or more pain scores could

be used when evaluating pain management. However, the size of needed pain

reduction is individual and depends on initial pain intensity. In general, a

change of approximately 2,5 points on an 11-point scale seems to represent

clinical significance for pain reduction.

Documentation of postoperative pain

Documentation of patients’ postoperative pain is included in a systematic

process of adequate management of pain (Gordon et al., 2005; Gordon et al.,

2008; Patient law, 2008:355). Different healthcare professions share

responsibility for the documentation of patients’ pain to ensure patients’ pain

control is provided under safe conditions. In Sweden, patients have access to

their medical records; therefore, the terminology must be understandable for

patients. Another aim of adequate documentation in medical records is to

deliver a tool for quality measures or research (Patient law, 2008:355).

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However, the use of structured nursing terminology is not well developed,

which has affected the incidence of healthcare professionals’ documentation of

patients self-reported pain (Saranto & Kinnunen, 2009). The documentation of

pain in medical records has been deficient irrespective of whether the

monitoring has been on paper or electronic (Fletcher et al., 2008; Carr et al.,

2014; Samuels & Eckardt, 2014). Deficiencies in electronic documentation have

been described as caused by poorly designed electronic medical records, EMR

(Saranto & Kinnunen, 2009, Stevenson, Israelsson, Nilsson, Petersson, & Bath,

2016), which has resulted in difficulties recognizing patients’ postoperative pain

traits (Carr et al., 2014; Samuels & Eckardt, 2014). Furthermore, reasons for the

fragmented documentation in EMR are related to individual knowledge and

given time frames for continuous documentation (Saranto & Kinnunen, 2009).

The introduction of EMR has increased the time needed to learn how to

document and find information needed in daily duties. An explanation for this is

that the EMR designs have failed to support care processes that include frequent

recordings of vital observations (Stevenson et al., 2016). Consequently, these

design shortages may put patient safety at risk due to delayed transfer of

information between healthcare professionals and perioperative care settings

(Braaf, Riley, & Manias, 2015; Saranto & Kinnunen, 2009).

Healthcare professionals’ roles in pain management

To provide pain relief is a humanitarian and ethical issue for healthcare

professionals (Ferell, 2005; Kotalik, 2012). The Bioethical Principles of

beneficence, non-maleficence, justice, and respect represent social justice and

human rights that can support healthcare professionals in their daily clinical

decision-making (Kotalik, 2012). Beyond the understanding of the physiologic

aspects of pain, the three concepts of relationship, compassion, and respect,

derived from Feminist Ethics can be applied to pain management, regardless of

whether the care is performed by a man or a woman (Ferell, 2005). The

awareness that illness, in this case pain, is not only a physiological event

increases the importance of treating the person in pain with compassion and

respect, and of taking an interest in the individual’s life experience (Ferell,

2005). The professional caring relationship with patients is determined by the

healthcare professionals’ dissimilar responsibilities as well as the individual

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interest in patients’ vulnerability when collecting different perspectives of

patients’ pain (Martin et al., 2010).

The collaborative role

Collaboration between healthcare professionals has been shown to have a

positive impact on quality of care (Havens et al., 2010; Martin, Ummenhofer,

Manser, & Spirig, 2010). The responsibilities held by the different professions

mean that all healthcare professionals involved in the care of patients after

surgery have an essential role to play in the pain assessment process (Gordon et

al., 2005). Inter-professional collaboration have strong associations with

information flow and the coordination of care (Havens et al., 2010; Martin et

al., 2010), and is suggested to have great opportunities for improvement in

postoperative settings (Meissner et al., 2015). Identified factors to enable good

inter-professional collaboration are described as both structural (joint

nurse/physician practice committees and integrated patient records) and

relational (Havens et al., 2010; Martin et al., 2010) Figure 1. From the

postoperative context, observations of nurses’ attention to patients’ pain

expressions revealed the need for collaborative discussions between different

healthcare professions to enhance the understanding of patients in pain (Manias

et al., 2004).

Figure 4. Modified model of relational coordination (Havens et al., 2010; Martin et al.,

2010)

Shared

goals/

leadership

Shared

knowledge

Frequent/ timely

and accurate

communication

Mutual

respect

Structural Relational

Inter-professional relational collaboration

Problem-

solving

communication

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The individual role

The knowledge of every healthcare professional’s responsibilities constitutes an

important ingredient of well-functioning care, Figure 4 (Havens et al., 2010;

Martin et al., 2010). In the Swedish context of postoperative care the physicians

described role is to conduct a deeper pain analysis, inform about the nature of

pain, its consequences and available treatment alternatives (Table 1). Before

surgery, they prescribe chosen peri- and postoperative treatments (Werner &

Leden, 2012). Postoperatively, nurses have a key role in the assessment and

documentation of patients’ pain. Furthermore, the nurses are responsible for the

distribution and evaluation of prescribed treatment, are delegated to give

treatment p.r.n and can also initiate use of non-pharmacological methods

(Werner, & Leden, 2010), Table 1.The enrolled nurses have completed

secondary school education and perform most of the “close patient care”. They

provide patient support when patients are in pain and perform repeated

postoperative pain assessments in post-surgical settings in Sweden. However,

their perspective on the caring for patients in pain is not found in research.

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Rationale

International and national guidelines advocate a thorough assessment of

patients’ postoperative pain as the basis for decisions on analgesia needs. In the

Swedish context, the closest team around patients who have undergone major

surgery consists of three healthcare professions; the enrolled nurse, the

registered nurse and the physician. In the aim to obtain pain management where

the patient is an active participant, the healthcare professionals’ individual roles

are equally as important as the coordination between the roles. Cultural norms

have a great influence on the different accompanying roles in each profession,

on the shaping of clinical care routines and the establishing of individual habits

of when and how to assess patients’ postoperative pain. The outcome of these

cultural norms, i.e. the degree of attentiveness of healthcare professionals to

patients’ symptom experiences are often referred to by patients as their

perceptions of the quality of care.

Regardless of the profession, the use of a validated pain scale when requesting

and documenting patients’ pain is included in international and national

guidelines on pain management. Although these recommendations exist, there is

limited research concerning the utility of pain scales in the postoperative

clinical context. Also, the understanding of how healthcare professionals choose

communication approaches when assessing pain is sparse. Therefore, healthcare

professionals’ perceptions and experiences of the use of pain scales, and from

their point of view significant features in the process of pain assessment need to

be explored.

Furthermore, it has been shown that documentation of patients’ postoperative

pain scores is unstructured and hard to find in patients’ medical records, which

consequently can delay care interventions and affect patient safety i.e. there can

be unwanted effects from under- or over-treatment of pain. Clinical decisions

based on patient-reported outcomes are known to improve patients’

involvement in decisions, which means that new motivational strategies are

needed to improve clinical use of patients’ self-rated pain. Recent research

suggests a simple approach, based on patient’s self-rated pain, to monitor

patients’ postoperative pain scores in medical records. Structured monitoring of

pain could contribute to increased motivation for clinical use of pain scales and

collaborative actions towards patients’ pain in daily surgical activities.

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Aim

The overall aim of this thesis is to describe the clinical utility of patients’ self-

rated postoperative pain after major surgery from the perspective of healthcare

professionals’.

The specific aims of the studies were:

to describe how healthcare professionals perceive the use of pain scales

in postoperative care (I).

through considering critical incidents to describe care experiences and

actions taken by healthcare professionals when assessing postoperative

pain (II).

to examine the clinical applicability of compiled mode and maximum

values from the NRS by comparing the correspondence between patient

perceptions of pain and pain values from monitoring records over 24

hours (III).

to (1) determine if a central tendency, median, based on patients’ self-

rated pain scores, is a clinically applicable daily measure to describe

patients’ postoperative pain on the first day after major surgery, and; to

(2) determine the number of self-ratings needed for the calculation of

this measure (IV).

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Conceptual framework

The concepts of care routines and communication were chosen to place the

results in a wider theoretical context when discussing the results that emerged

from the four studies. These concepts have a close relation to the clinical

context, i.e. the healthcare professionals’ duties on general and orthopaedic

surgery wards.

Care routines

The routine as a phenomenon is influenced by cultural norms and values

(Becker, 2004). The care culture at workplaces consists of both organizational

care routines and healthcare professional’s individual routines and habits

(Rytterström, Unosson, & Arman, 2010). Organizational routines are described

as contributing to stability, and enable coordination and consistency in an

organization, and thus are slow to change (Becker, 2004). Healthcare

professionals’ individual care routines and habits are shaped by the specific

field in which they occur (Lauzon-Clabo, 2007; Nilsen, Roback, Broström, &

Ellström, 2012) and are defined as being a response to the context, i.e. the

guidelines describing care routines, values and beliefs in the actual care setting

(Nilsen et al., 2012). Existing knowledge of behaviour formation is based on

overall social cognitive theories (Nilsen et al., 2012), and behaviour changes are

suggested to relate to perceived motivation, intentions, attitudes, and behaviour

control (Becker 2004). Cultural and social norms unique to the specific setting

can explain why certain pain assessment behaviours are given primacy and

whether patients’ pain expressions are believed or not (Harper et al., 2007;

Lauzon-Clabo, 2007).

A meaningful care routine has been described to be in harmony with one’s own

cultural beliefs and is easy to adapt to (Rytterström et al., 2011). By learning

and repeatedly performing routine tasks, they eventually become established

habits. Gradually these habits become subconsciously performed (Becker,

2004). Ones established, the habits are beneficial for the individual because they

utilize less time and cognitive resources (Becker, 2004) and behaviour

consequences are well known (Nilsen et al., 2012). This comfortable “shortcut”

in everyday practice can explain why habitual behaviours dominate healthcare

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professionals’ daily practice and continue once they are settled, even when

motivation is lost (Nilsen et al., 2012) or despite newly presented evidence

(Becker, 2004).

Communication

The word communication comes from the Latin word “communicatio” which

means “make common” (Fossum, 2013). Communication is the information

component of interaction where the interaction is a kind of verbal or non-verbal

action in which two or more objects have an effect upon one another (Fossum,

2013). Healthcare professionals’ communication is one of the fundamentals for

the understanding of patient’s health condition (Arman, Ranheim, Rydenlund,

Rytterström, & Rehnsfeldt, 2016). The idea of two-way dialogue means

mutually participating to reach a common understanding; however, some

asymmetries of influence and participation will always be present (Linell,

2004). The caring dialogue involves listening, engaging, and responding with

empathy, being honest and trustworthy. It also encompasses eye contact, body

language, tone, voice, and attitude (Waters & Whyte, 2012). To achieve an

understanding of patients’ needs from a holistic perspective, three successive

phases of communication have been described; orientation (getting to know

each other), working (identifying patients’ reactions to their illness) and

resolution (preparing the patient to move on) (Peplau, 1997). Additionally, an

understanding between healthcare professionals and patients is achievable when

the sense of the action becomes evident for both partners and goals are defined

(Sieger, Fritz, & Them, 2012).

In healthcare, information transfer typically flows in one direction from the

provider to the recipient (Lee & Garvin, 2003). The movement from

information transfer to information exchange and understanding-orientated

interactions, i.e. the two-way dialogue, is continuously problematized (Lee &

Garvin, 2003; Liu, Gerdtz, & Manias, 2016). Reasonable causes of the

dominating use of information transfer are healthcare professionals’ and

patients’ different perspectives, along with unavoidable asymmetries in health

conditions, medical knowledge and accompanying discourse, and participation

status (Linell & Luckmann, 1991). How active the patients become in decisions

(Chaboyer et al., 2016) and how they will perceive the quality of care

(Schwenkglenks et al., 2014) are shown to be determined by the perceived

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quality of the communication. Equal communication, where an agreement

springs from a dialogue is however, still not obvious in care settings. Liu et al.

(2016) have shown that vocabulary reflects the complex power relations

between patients and healthcare professionals, and among healthcare

professionals’ themselves. Healthcare professionals’ language in acute settings

is still authoritative and instructive, while patients’ discourse is polite. In

postoperative care, targeted questions have been shown to be most common

when assessing patients’ pain (Manias et al., 2004; Schafheutle et al., 2004).

Among healthcare professionals, nurses have historically had a subservient role

to physicians, which has given the physicians the power (Foronda, Mac

Williams, & Mc Arthur, 2016). Identified frustrations in inter-professional

communication are described as characterized by not only power relations but

also the differences in how nurses and physicians are trained (Foronda et al.,

2016). The differences in communication styles may generally be caused by the

nurses’ focus on the holistic perspective in patients’ health condition while the

physicians’ focus is on the objective structured essence (Foronda et al., 2016).

However, these cultural professional differences can, if they are taken into

consideration, have a broadening impact on perspectives in care and can benefit

safe patient care (Martin et al., 2010; Foronda et al., 2016).

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Methods

Design

To achieve the overall aim of the thesis, different qualitative and quantitative

methods were used. The chosen explorative designs provided approaches to:

find variations in the studied phenomena of healthcare professionals’ utility of

patients’ self-reported pain (I), and to find variations in healthcare

professionals’ experiences and actions when assessing postoperative pain (II).

Furthermore, a cross-sectional design was used to study the agreement between

two measures of patients’ self-rated pain (III). This was also the aim of the

repeated measure design in study IV. An overview of the design, setting,

participants, data collection and data analysis of study I-IV is presented in Table

2.

Table 2: Overview of the design, setting, participants, data collection and analyses (I-

IV)

Study Design Setting Participants Data collection

Data analysis

I Explorative one

university

three

county

hospitals

25 healthcare

professionals

semi-

structured

interviews

Phenomeno-

graphic

approach

II Explorative one

university

three

county

hospitals

24 healthcare

professionals

semi-

structured

interviews

Critical

Incident

Technique

III Cross-

sectional

one county

hospital

157 patients questionnaire

monitoring

records

Spearman

correlations

IV Repeated

measure

three

county

hospitals

479 patients questionnaire

study

protocol

Spearman

correlations

Svensson

method, free

software

program

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25

Setting

The data was collected in the context of orthopaedic and surgical wards at one

university and three county hospitals in the south of Sweden. The catchment

areas were both rural and urban with 900,000 inhabitants. The number of beds

in the four included hospitals varied between 300 and 600. Three of the

hospitals had pain assessment routines with varying details, according to the

guidelines of Allvin & Brantberg (2014). At the fourth hospital, there were

healthcare professionals who used pain scales when assessing pain despite the

lack of written routines.

Participants

Studies I and II

Healthcare professionals with knowledge of the area i.e. clinical experience of

pain scales in postoperative, care were continuously recruited by research

nurses at the included units. The selection was based on age, sex, healthcare

profession and experience of orthopaedic or general surgery. In study I, a

purposeful sample of 25 healthcare professionals was selected and included

between June and November 2012. In study II, a strategic sample of 24

healthcare professionals was selected during a period of nine months between

December 2013 and October 2014. Socio-demographic data are shown in Table

3.

Table 3: Socio-demographic data of healthcare professionals (I, II)

Category Study I N=25

Study II N=24

Age; years M/[range] 41[23-63] 39[24-60]

Sex; male/female 6/19 7/17

Profession; enrolled nurses/nurses/physicians 6/15/4 7/11/6

Years of experience in postoperative care;

1-5/6-10/>10

8/6/11

11/4/9

Employment; general surgery/orthopaedic 8/17 12/12

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Studies III and IV

The convenience sampling consisted of the first consecutive patients

undergoing major surgery who were expected to stay in hospital care for ≥2

days. Major surgery is a surgical procedure that often requires general

anaesthesia, is extensive, involves removal of organs and requires postoperative

hospital care (Encyclopedia, 2017). Inclusion criteria were patients 18 years or

older, undergoing scheduled major general or orthopaedic surgery, expected to

have a length of stay ≥2 days, orientated to time and environment, and able to

understand both spoken and written Swedish language. The exclusion criterion

was transfer to intensive care postoperatively. In study III, 190 patients were

asked to participate, of whom 171 were enrolled between April and October in

2009. A total of 157 patients (54.8% male, mean age 63 years) completed the

first study day i.e. postoperative day 2. Orthopaedic patients (64.3%) dominated

the group. Missing data varied from 0-5%. A total of 71.9% of the patients who

had completed the questions had ≥4 monitored pain ratings on postoperative

day 1. In study IV, 582 patients were asked to participate, of whom 541 were

enrolled from October 2012 until January 2015. A total of 479 patients (55.9%

male, mean age 65.2 years) completed the study. Orthopaedic patients (60.3%)

dominated the group. Patients’ self-rated pain was to be registered at rest and

during activity in a study protocol (Appendix 2). The proportion of patients who

had their pain scores registered ≥4 times was 81.6% at rest and 75.2 % during

activity, and ≥6 times 29.0% at rest and 22.7% during activity. No patient had

their scores registered more than nine times. Retrospective average pain at rest

and during activity was reported by 97.9% and 97.3% patients respectively.

Socio-demographic characteristics and clinical data are shown in Table 4.

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Table 4: Socio-demographic characteristics and clinical data of patients (III and IV)

Category III n=157

IV n=479

Surgery; general surgery/orthopaedic 56/101 190/289

Age; years m/[range] 63.3[21-88] 65.2[22-93]

Sex; male/female, n (%) 86(54.8)/71(45.2) 268(55.9)/211(44.1)

Country of birth; Sweden/other, n (%) - 451(94.2)/27(5.6)

Preoperative pain:

6 month prior to surgery, n (%)

85(54.1)

-

Daily intake of analgesiab:

6 months prior to surgery, n (%)

81(51.6)

210(44.0)

ASAa I-II - 407(85.0)

Education

elementary/ secondary

school/ university, n (%)

- 197(41.1)/166(34.7)

/ 112(23.4)

Type of surgery, n (%)

Urology 16(10.2) 93(19.4)

Abdominal 30(19.1) 89(18.6)

Vascular 5(3.2) 6(1.3)

Other general surgery 5(3.2) 2(0.4)

Knee replacement 45(28.7) 76(15.9)

Hip replacement 19(12.1) 149(31.1)

Neck and back 20(12.7) 49(10.2)

Other orthopaedic 17(10.8) 15(3.1)

Anaesthesia:

regional/ sedation/ general, n (%)

-

245(51.1)/167(34.9)

/267(55.7)

Postoperative analgesia:

opioidsc/epidurals, n (%)

-

362(77.5)/120(25.5) aASA, American Society of Anesthesiologists physical status classification,

bNon-

opioids: paracetamol, NSAIDs, opioids: codeine, tramadol, morphine, oxycodone,

fentanyl, buprenorfin, cOpioids: tramadol, morphine, oxycodone.

Data collection

Qualitative data

In studies I and II, data consisted of interviews. The semi-structured interviews

were designed in line with the traditions of the chosen qualitative approaches

(Marton & Booth, 1997; Bradbury-Jones & Tranter, 2008). Arrangement with

clinic managers allowed the participants to leave their work responsibilities

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during the interviews, and gave access to quiet rooms at their place of work.

The interviews started with an informal chat where the importance of every

person’s contribution, regardless of profession, was underlined. Furthermore,

the significance of concrete self-perceived experiences was emphasized.

In study I, the interview guide (Table 5) was inspired by the pain assessment

recommendations from the American Pain Society (Gordon et al., 2005).

Reminders that perceptions were asked for and probing questions such as

“How/What do you mean by that?”, “Could you explain more?” “Could you tell

me how?” were used when needed. The interviews lasted between 20 and 40

minutes, were audiotaped and transcribed verbatim. The transcribed text

comprised of 242 double-spaced pages (A4).

Table 5: Interview guide used in the data collection with healthcare professionals

(N=25) (I)

Interview guide (I)

How do you perceive the importance of assessment with a pain scale

during the first postoperative days?

How do you perceive your responsibility/role in pain assessment?

How do you perceive the patients’ responsibility/ role in pain

assessment?

How do you perceive pain assessment in relation to action/pain

treatment?

In study II, the interview guide (Table 6) was designed to elicit both positive

and negative perspectives on the chosen incident, which was in line with the

existing nursing research culture when using the Critical Incident Technique

(CIT) (Bradbury-Jones &Tranter, 2008). Probing questions were used such as:

“Can you describe more about what you or the patient said or did?”, “Was there

something affecting the assessment situation?”, “Why was this critical incident

important to you?” The interviews lasted between 30 and 70 minutes, were

audiotaped, and transcribed verbatim. The transcribed text comprised 535

double-spaced A4 pages.

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Table 6: Interview guide used in the data collection with healthcare professionals

(N=24) (II)

Interview guide (II)

Describe an incident when a patient was in pain and you assessed the pain.

What contributed to your understanding of the patient’s pain?

How was the situation handled?

Did the event result in something positive or negative for the patient’s pain?

Quantitative data

In studies III and IV the socio-demographic and clinical data was collected by

research nurses. The healthcare professionals who were responsible for the

included patients’ care were instructed on postoperative day 1 to ask for and

monitor the included patients’ self-rated pain (NRS) every fourth hour, when

breakthrough pain occurred, and at reassessments (Appendix 2). If the patient

was asleep, no assessment of pain was made. Additionally, questionnaires

(Appendix 1-2) were delivered to the included patients on the morning of

postoperative day 2, Table 7.

Table 7: Data collection of patients’ NRS self-rated pain scores and patients’

retrospective self-rated pain (III, IV)

Data collection (III,IV)

III

(n=157)

Measure I: repeated self-rated pain scores (NRS 0-10),

collected on postoperative day 1

Measure II: retrospective self-rated pain (0-3, 4-6, 7-10) from

postoperative day 1; collected day 2

IV

(n=479)

Measure I: repeated self-rated pain scores at rest and during

activity, collected postoperative day 1

Measure II: retrospective pain intensity from postoperative

day 1; average pain scores at rest and during activity,

collected day 2

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Self-reported pain

In studies III and IV, the patients reported their postoperative pain experiences

with the NRS, a pain-scale that is included in international (Gordon et al., 2005)

and national (Brantberg & Allvin, 2016) guidelines of pain assessment. The

NRS has been tested regarding construct validity and psychometric properties

(Williamson & Hoggart, 2005) and is the scale preferred by most adults

regardless of age and culture. It is thereby considered valid in most settings

(Gagliese, Weizblit, Ellis, & Chan, 2005; Hjermstad et al., 2011). In line with

the local guidelines at the included wards, the NRS with the anchors 0=No pain

and 10=Worst possible pain was used.

Questionnaires

A questionnaire (Appendix 1) was constructed for study III. In this thesis, the

results from three questions regarding retrospective perceptions of intensity and

duration of pain were included. The NRS was dichotomized into the three

groups of pain: mild pain (0-3), moderate pain (4-6) and severe pain (7-10),

which were seen in studies measuring pain (Melotti et al., 2005; Zelman,

Dukes, Brandenburg, Bostrom, & Gore, 2005; Couceiro, Valença, Lima, de

Menezes, & Raposo, 2009). In the created groups; NRS 0-3, 4-6 and 7-10, the

three alternatives of duration of pain; >1 hour, <1hour or no pain were asked

for. The questions were based on guidelines (APS, 1995; Gordon et al., 2005)

and literature of relevance (Jensen & Karoly, 2001; Williamsson & Hoggart,

2005). Face and content validity were assessed by the research group, patients

and different professionals with experience of postoperative care. The

questionnaire (Appendix 2) from study III was further developed in study IV by

the research team. Statisticians involved in the construction of the instruments,

mainly assessed analysis possibilities. In this thesis, the results from two

questions regarding retrospective perceptions of pain intensity at rest and during

activity were used in study IV. The remaining questions in Appendices I and II

were used in other studies about patients’ pain and recovery; Postoperative pain

assessment and impact on early physical recovery, from the patients’

perspective (Eriksson et al., 2017).

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Data analysis

Qualitative (I)

Perceptions of the surrounding world i.e. how various aspects of the

phenomenon (pain assessment with one-dimensional pain scales) were

understood by healthcare professionals were explored with a phenomenographic

approach. This approach differentiates between the first order perspectives i.e.

the real facts that can be observed, and the second order perspective i.e. how

something is perceived or understood (Marton & Both, 1997). The aim is to

explore and understand the nature of an individual’s different understandings of

the studied phenomena (Sjöström & Dahlgren, 2002). Data analysis was

performed in accordance with the phenomenographic tradition (Sjöström &

Dahlgren, 2002) (Table 8). The underlying structure of variance i.e. the second

order perspective was sought in collected data (Marton & Both, 1997). The

corresponding statements were condensed and grouped into 13 descriptive

perceptions. After thorough discussions, the perceptions were compared

regarding similarities and differences and were grouped into different distinct

perceptions. The perceptions that related to each other formed the descriptive

categories. Lastly, the structure of the phenomenographic outcome space was

investigated to identify the internal hierarchical relations between the emerged

categories (Larsson & Holmström, 2007).

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Table 8: The phenomenographic data analysis approach according to Sjöström &

Dahlgren, 2002 and Larsson & Holmström, 2007, (I)

Data analysis

Familiarization. Collected data was read several times to obtain a sense of the

whole.

Compilation. A total of 420 significant statements corresponding to the aim of

this study were identified.

Condensation. Statements were reduced.

Grouping. Groupings into17 pre-perceptions were made.

Comparison. The included statements in the pre-perceptions were thoughtfully

read to ensure similarities within the perception and differences between the

perceptions.

Naming. Perceptions and the emerged descriptive categories were named with

adequate levels of abstraction.

Contrastive comparison. The obtained descriptive perceptions and categories

were compared in terms of similarities and differences. Four descriptive

categories and 13 perceptions were established.

Hierarchical relations. Investigation of the hierarchical relations between the

four categories was carried out.

Qualitative (II)

Collected positive and negative critical incidents were explored with the CIT. A

critical incident describes a retrospectively significant experience, in this study

the assessment of a patient in pain followed by a human behaviour, i.e. actions

taken to understand a patient’s pain, that is crucial for the outcome of the

described incident (Flanagan, 1954). The context, i.e. information about

locality, involved persons and their activities’, in which the incident occurred is

of importance as the aim of the CIT approach is to provide behavioural

solutions to practical and clinical problems (Flanagan, 1954; Bradbury-Jones &

Tranter, 2008). The identified incidents were classified either as a care

experience or a care action. These two groups were analysed separately,

according to the framework of Fridlund, Henricsson, & Mårtensson, (2017).

Care experiences represented critical incidents affecting the pain assessment

situation, while care actions represented actions taken to understand patients’

postoperative pain. Finally, the distinct separated but related subcategories were

grouped into descriptive categories and main areas (Table 9).

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Table 9: The CIT approach data analysis according to Fridlund et al., (2017), (II)

Data analysis

Analysis initially involved familiarization with the 24 transcribed interviews of

535 double-spaced A4 pages by reading them several times.

486 critical incidents were identified and defined either as a care experience

(205) or a care action (281).

Two groups of descriptive subcategories were formed and further analysed

separately; 14 care experiences and 19 care actions.

Four categories of care experiences and six care actions emerged and were

finally abstracted to main areas; two care experiences and three care actions.

Naming of the categories reflected the distinct differences of the categories and

the level of abstraction to emphasize their essence.

Quantitative methods

In study III, descriptive statistics described demographic and clinical data. The

agreement of individual calculated mode and maximum measures from the

monitoring records versus the retrospective stated pain (>1 hour, < 1 hour, no

pain in the created groups of NRS 0-3, 4-6, 7-10) was analysed by Kappa

statistics, measuring inter-rater agreement of qualitative items. Due to the low

frequency of patients who rated NRS 7-10, the three response alternatives (NRS

0-3, 4-6, 7-10) were dichotomized into two groups, those with an NRS score of

0-3 and those with score of 4-10, where 0-3 is considered mild- and 4-10

moderate to severe pain. IBM SPSS Statistics 21 (IBM Corp, Armonk, NY) was

used for the analyses of the data.

In study IV, descriptive statistics were used to describe socio-demographic and

clinical data. The prevalence of pre- and postoperative pain, day 1, was reported

as median and quartiles. Non-parametric tests (Mann-Whitney U test, Wilcoxon

Rank Test) were used to test for differences of pain between the groups of

general- and orthopedic surgery.To determine the associations between the

individual calculated mode and median scores from measure I and retrospective

self-rated average pain scores from measure II (Table 7), Spearman rank

correlations were used based on four to nine self-rated pain scores from

measure I. Created groups of patients who had exact 4, 4-9, 5-9 and 6-9

recorded ratings were analysed separately. Patients who had fewer than four

ratings were deemed inappropriate to include in statistical analyses and were

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therefore excluded. IBM SPSS Statistics (IBM Corp, Armonk, NY) was used

for the analyses of the data. To determine patterns for change between the

measures, analyses to measure pairwise agreements, systematic disagreements

and individual variability separately were performed with the Svensson’

Method in a free software program (Avdic & Svensson, 2010).

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Ethical considerations

In this thesis, ethical guidelines based on the Declaration of Helsinki were

followed. Approval from the Regional Ethical Review Board in Linköping,

Sweden (No. M249-09 and No 2012/40-31) was obtained to perform the four

studies. Researcher guidance using the four main principles, respect for

autonomy, non-maleficence, beneficence and the principle of justice was

deemed applicable in this thesis (Northern Nurses Federation 2003; The World

Medical Association [WMA], 2013).

Respect for autonomy

Patients who were not able to comprehend information were not included. This

is an ethical dilemma as their needs are difficult to identify. However, a deeper

knowledge of different communication approaches in assessments of pain can

be transferable to this group of patients. Voluntariness was highlighted during

the whole inclusion process and at collection of data. To avoid participants’

dependence on the researcher, the researcher did not collect data when a care

(Studies III, IV) or close professional (Study I, II) relationship existed.

Non-maleficence - Beneficence

The risk of harm was deemed small. Data were reported in such a manner that

no individual could be identified. The benefits of obtaining a deeper knowledge

of how to assess patients’ postoperative pain were considered to weigh up

potential risks. Included patients expressed a sincere interest in contributing to a

deeper knowledge as future patients can benefit from the increased

understanding of postoperative pain experiences. Furthermore, the interviewed

healthcare professionals described positive effects of being interviewed, which

is consistent with other researchers’ experiences (Doody & Noonan, 2013).

However, it is known that interviews with healthcare professionals may reveal

bad performances that could cause feelings of failure (Doody & Noonan, 2013).

As the interviewer could foresee this dilemma the interviewer consciously

remained neutral to given descriptions and non-verbal behaviour.

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The principle of justice

Persons eligible for the four studies were asked for participation regardless of

ethnicity, sex, or socio-economic status. Participating patients in study III and

IV were more likely to have opportunities to express their pain during their first

postoperative days. This was related to the study protocol where healthcare

professionals were asked to assess and document patients’ self-rated pain

frequently. The reporting of results in peer-reviewed journals and the spreading

of results at national and international conferences justify the involvement of

patients and healthcare professionals.

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Results

Perceptions of the utility of pain scales (I)

In summary, healthcare professionals’ perception of the utility of pain scales

was that the scales facilitated the understanding and treatment of postoperative

pain. Thus, pain assessments demanded a multi-dimensional communication

approach and were affected by work situations (Table 10).

Pain scales facilitated the understanding of patients’ pain. Patients’ monitored

pain scores visualized pain severity trajectories and served as a common

language. Individualized intervals of assessing pain made it possible to find

patients who were in pain; moreover, pain in different situations became known.

Pain scales facilitated treatment of pain by healthcare professionals being “one

step ahead” in controlling pain. Furthermore, repeated pain scores were useful

when choosing pain-relieving strategies. The effort to keep patients’ pain scores

low, with respect to side effects and ability to mobilize, facilitated patient

comfort, and enabled patients to return home. The understanding of patients’

self-rated pain however demanded a multi-dimensional approach. Dialogues

were used to reach mutual understanding of the meaning of patient’s pain

scores. Furthermore, observations of behaviours and vital signs were needed to

avoid neglecting patients who did not want to talk about their pain.

The utility of pain scales was affected by work situations. The healthcare

professionals, who considered themselves to possess knowledge of pain scales,

described spending time explaining and motivating patients’ pain-scoring. They

were also aware of the risk of adding their own values to patients’ ratings, and

of patients comparing their ratings with those of others. Encouragement from

the ward management and combined pain assessments with other care routines

constituted stimulating factors, while established habits of excluding pain scales

and poorly designed EMR were perceived as barriers.

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Table 10: Healthcare professionals’ perceptions of the use of pain scales in

postoperative pain assessments, (I)

Descriptive categories Perceptions

The use of pain scales facilitated the

understanding of patients’ pain

Pain scales facilitated the discovery of pain

Pain scales visualized the pain progress

Pain scales facilitated handover between

healthcare professionals

The use of pain scales facilitated

treatment of pain

Pain scales facilitated prevention of pain

Pain scales facilitated choice of pain

treatment

Pain scales facilitated evaluation of pain

treatment

The use of pain scales demanded a

multi-dimensional approach

Pain scales demanded additional assurance

of patients’ understanding

Pain scale interpretation demanded

additional dialogue

Pain scale interpretation demanded

additional observations

The use of pain scales was affected

by work situations

Pain scale usage was affected by

healthcare professionals’ knowledge

Pain scale usage was affected by habits of

healthcare professionals

Pain scale usage was affected by

management

Pain scale usage was affected by

prioritizing of tasks

The internal relationship between the descriptive categories was of a logical

hierarchical form, as illustrated in Figure 6. The perception that pain scales

facilitate treatment of pain is dependent on the perception that pain scales

facilitate the understanding of patients’ pain experience. To use the pain scales

properly, several factors (Table. 10) were needed concerning the work situation.

Furthermore, the insight of the additional multi-dimensional communication

approach, tailored to the patients’ communication abilities, determined the

outcome of the understanding of pain, i.e. facilitated pain treatment decisions.

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Figure 6. The hierarchical structure of the phenomenographical outcome space of

healthcare professionals’ perceptions of the use of pain scales in postoperative pain

assessments, (I)

Care experiences when assessing pain (II)

Healthcare professionals’ descriptions of their care experiences revealed the

importance of the understanding of patients’ wide variation of pain expressions

and communication ability. Healthcare professionals’ clinical competence and

work conditions determined whether the understanding of patients’ pain

expressions was achieved (Table 9).

Patients’ communication abilities affected healthcare professionals

understanding of patients’ pain. Detailed descriptions that matched behaviours

facilitated healthcare professionals’ assessment, while various patient-related

barriers, i.e. mismatching pain scores with observed behaviours, patients’ pre-

or post-surgery health conditions, language deficiencies, patients’ unwillingness

to report pain hindered efficient communication.

Healthcare resources i.e. healthcare professionals’ clinical competence and

working conditions determined the level of healthcare professionals’

performance in pain assessments. Clinical competence contributed to the skills

of sensing patients’ pain during care, while clinical decisions became

troublesome when patients responded differently to the majority and when

experiences of effects from analgesia were restricting. High turnover of

The use of pain scales facilitated treatment of pain

The use of pain scales facilitated the understanding of pain

The use of pain scales was

affected by work situations

The use of pain scales demanded

a multi-dimensional approach

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40

healthcare professionals put patients at risk for having to repeat their history of

pain, while continuity of care increased knowledge of patients’ pain (Table 11).

Table 11: Healthcare professionals’ experiences when assessing postoperative pain, (II)

Main areas Categories

Patients’ communication abilities

Patients’ pain expressions

Patients’ barriers to pain expressions

Healthcare resources

Healthcare professionals’ clinical competence

Healthcare professionals’ working conditions

Care actions when assessing pain (II)

Healthcare professionals described the actions of gathering facts, adapting to

patients’ communication abilities, and the utilizing of healthcare resources

(Table 12).

Information on patients’ pain was normally collected by asking questions while

observing pain expressions. Whether the observations were made with or

without conscious reflections, patient’s pain at rest and during activity was the

basis for clinical decisions. Pain qualities were exclusively investigated when

pain was unexpected. Ideally, patients’ narratives were listened to and

confirmed, but limited time could necessitate leading questions. The given time

frames normally resulted in patient’s previous experiences being given less

attention. Healthcare professionals adapted to patients’ communication abilities

when assessing pain, which meant that their actions were aimed at getting to

know their patients’ personalities and their ability to use pain scales. If patients’

self- rated pain scores were not understandable, their understanding of the NRS

scoring was ascertained. Healthcare professionals’ actions to ensure their

understanding of patients’ pain expressions were associated with the

importance of safe administration of analgesia. Patients who were perceived to

have unintelligible pain expressions were offered analgesia and observed either

in agreement or unknowingly.

The use of surrounding healthcare resources was described as increasing the

quality of pain assessments in difficult situations. A well-functioning

collaboration between internal resources i.e. enrolled nurses, nurses and

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41

physicians normally fulfilled significant needs. When usual postoperative

analgesia was insufficient, acute pain specialists contributed time and

knowledge. Also, relatives, physiotherapists and social workers were asked to

add their perspectives on patients’ pain.

Table 12: Healthcare professionals’ actions when assessing postoperative pain, (II)

Main areas Categories

Healthcare professionals gather facts

about patients’ pain manifestations

Healthcare professionals gather

information from patients’ pain

expressions

Health care professionals gather

information about patients’ pain

treatment

Healthcare professionals’ adaptations

to patients’ communication abilities

Healthcare professionals ensure

patients understand pain assessments

Healthcare professionals ensure they

understand patients’ pain expressions

Healthcare professionals use

healthcare resources

Healthcare professionals collaborate

Healthcare professionals consult

external care resources

Prevalence of pain (III, IV)

In study III, when the NRS was dichotomized into NRS 0-3 (mild pain) and 7-

10 (moderate- to severe pain), 43% of the patients had experienced average

(mode) moderate to severe pain. Maximum moderate to severe pain was

experienced by 73% of the patients (III) and by 74% during activity (IV). In

study IV, the whole range of the NRS was used. The proportions of patients

who experienced average (mode) of moderate to severe pain at rest were 22%

and on activity 57%.

The orthopaedic patients were found to experience more pain before and after

surgery compared to the general surgical patients (IV) (Table 13), while the

orthopaedic group experienced significantly lower postoperative pain than

preoperatively, Wilcoxon Rank Test p<.001. Furthermore, patients’ pain at rest was

significantly lower than during activity in the general surgery group and the

orthopaedic group, Wilcoxon Rank Test p<.001.

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42

Table 13: Pre- and postoperative pain for the total sample and the general and

orthopaedic surgery groups, NRS md, (q1-q3) and retrospective average pain (q1-q3),

(IV)

aMann-Whitney U test,

*** = <.001, Wilcoxon Rank Test

42

Total N=479

General surgery n=190

Orthopaedic surgery n=289

n

Measure

I

Measure

II

Measure I Measure

II

p-

value

Measure I Measure

II

p-

value

Prehospital pain

at rest

md(q1-q3)

474

2(0-5)

-

0(0-2)

-

<.001a

4(2-6)

-

<.001a

Prehospital pain

during activity

md (q1-q3)

469

6(1-8)

-

0(0-2)

-

<.001a

7(6-8)

-

<.001a

Postoperative

pain at rest

md (q1-q3)

469

2(0-4)

3(2-5)***

1(0-2)

2(1-3)***

<.001a

3(1-4)

4(2-5)***

<.001a

Postoperative

pain during

activity

md (q1-q3)

466

4(3-7)

5(3-7)***

3(2-5)

4(2-5)***

<.001a

5(4-7)

6(4-8)***

<.001a

43

The clinical applicability of daily summarized measures

based on patients’ self-reported pain (III, IV)

Alternative daily measures, based on patients’ self-rated pain after major

general and orthopaedic surgery with the NRS were explored in studies III and

IV. The calculation of average measures from patients’ self-rated pain showed

acceptable reliability when the whole range of the scale was used (III, IV).

When the scale was dichotomized into the groups of 0-3 and 4-10, reliability

increased (III).

The mode (III, IV) and maximum measures (III)

The results (III) demonstrated high reliability for daily mode and maximum

measures, based on ≥4 pain scores, of postoperative pain when the created

groups of NRS 0-3, 4-6 and 7-10 were dichotomized into the groups of 0-3 and

4-10. Patients reported pain scores (measure I), showed a strong correlation

versus their retrospective reported pain on postoperative day 1 (measure II);

mode: rs=.95, (p<.001) and maximum: rs=.95 (p<.001). Correlational strength

decreased when the NRS groups of 0-3, 4-6 and 7-10 were analysed, mode:

rs=.37, maximum: rs=.53.

In study IV the measures were changed to pain at rest and during activity.

Additional analyses of data from the sample in study IV showed that the mode

measures from postoperative day 1, had acceptable reliability when the full

range of the NRS was used. Rank correlations for the calculated individual

mode scores (measure I), based on four ratings, versus retrospective average

reported pain (measure II) were, rs =.51 (p <.001) at rest and rs =.57 (p <.001)

during activity. A “trend” towards increased correlational strength up to rs =.61

(p <.001) at rest and rs =.60 (p <.001) during activity was seen with strengthened

with increased numbers of ratings (Table 14).

The median measures at rest and during activity (Study IV)

The results demonstrated acceptable reliability for the median measures at rest

and during activity the day after surgery when the full range of the NRS was

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44

used. Rank correlations for the calculated individual median scores (measure I)

versus retrospective average reported pain (measure II) showed the same pattern

as for the mode measure i.e. a “trend” towards increased correlational strength

with increased number of pain ratings (Table 14). The differences between

measures I and II at rest were due to patients significantly higher reported

retrospective average pain compared to the median pain that was calculated

from the pain ratings “right now” in measures I and IV (Table 15).

Table 14: Spearman rank correlations between individual average scores (Mode and

Md) from measure I, versus retrospective average pain from measure II, pain at rest and

during activity (IV)

Number of pain ratings 4a 4-9

b 5-9

c 6-9

d

Average (Mode) pain at rest .51**

.60 **

.60 **

.61**

Average (Mode) pain on activity .57**

.61 **

.62 **

.60 **

Average (Md) pain at rest .61 **

.64 **

.67 **

.68 **

Average (Md) pain on activity .57 **

.64 **

.66**

.62 **

Patients with: a exactly four,

b four to nine,

c five to nine,

d six to nine self-ratings of

pain.

The Svensson’ method (IV) was used to further explain patterns of change

between the two measures (Table 15). Percentage of agreement was 27% at rest

and 26% during activity. The systematic group changes (RP) at rest were

significant and demonstrated higher recalled pain scores in measure II at rest

compared with the individually summarized medians from postoperative day 1,

measure I. No concentration (RC) to a certain score on the NRS was seen and

the individual variation (RRV) 0.18 was within the expected outcome. During

activity, there was no significant systematic group change (RP) or concentration

(RC) to a certain NRS score. The individual variation (RRV) 0.23 was close to

the expected outcome of 0.20. These results suggest that both group and

individual variations in reported pain caused disagreements between the two

measures at rest while individual variations were the main source of

disagreements during activity.

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45

Table 15: The Svensson analyses of patterns of change between measures I and II (IV)

Percentage Agreement, PA

Relative

Position,

RP(95% CI)

Relative

Concentration,

RC (95% CI)

Relative Rank

Variation,

RRV(95% CI)

Pain at

rest

27 0.18

CI: 0.13-0.24

0.06

CI:-0.01–0.13

0.18

C I: 0.13–0.22

Pain on

activity

26 -0.09

CI: -0.14–0.05

-0.06

CI: -0.14–0.03

0.23

CI: 0.16–0.29

The patterns of change are visualized in Figures 7a and b. The staples

representing proportions of patients (measures I and II) for each score on the

NRS show that the majority of patients who reported no pain to the nurses, with

a median of NRS 0, retrospectively reported higher average pain scores.

Additionally, the proportion of patients who obtained high pain scores, median

of 7-10, was lower than was retrospectively reported.

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46

Figure 7: Proportion of patients with average pain, NRS 0-10 in measures I and II, a: at

rest and b: on activity

46

a.

b.

% of patients

No pain 1 2 3 4 5 6 7 8 9 Worst pain

0

5

10

15

20

25

30

35

Measure 2 RestMeasure 1 Rest

% of patients

No pain 1 2 3 4 5 6 7 8 9 Worst pain

0

5

10

15

20

25

30

35

Measure 2 ActivityMeasure 1 Activity

47

Discussion

Methodological aspects

This thesis involves the collection of ordinal data (NRS 0-10) and data from

semi-structured interviews with two different philosophical approaches.

Whether results are verified as the truth depends on how truth is defined. In the

shift from the strict positivism paradigm to the post positivism paradigm, which

is still valid, the interpretation process of research results came to include the

skills and experiences the researchers possess (Holloway & Wheeler, 2009),

which means that research is significant regardless of whether the results are

based on quantitative or qualitative data (Polit & Beck, 2017). Acknowledged

concepts of validity, reliability and generalization are applied to quantitative

data (Polit & Beck, 2017) and trustworthiness for qualitative data in this thesis

(Holloway & Wheeler, 2009).

Trustworthiness (Study I, II)

The qualitative terms of credibility, dependability, confirmability and

transferability derives from the corresponding quantitative terms in quantitative

research; internal validity, reliability, objectivity and generalizability (Polit &

Beck, 2017).

Credibility refers to the truth of interpretation of data (Holloway & Wheeler,

2009). The composition of the research team, which consisted of researchers

with experience of acute postoperative pain services and qualitative research,

met the expectations of research qualities within the chosen qualitative methods

(Flanagan, 1954; Sjöström & Dahlgren, 2002; Holloway, & Wheeler, 2009)

Interviews were conducted by the main researcher who initially had limited

experience of interviewing, which may have affected the quality of the first

interviews. However, accurate collection and interpretation of data was

continuously evaluated by involving the whole research team in the different

steps of research production until consensus was reached.

Dependability refers to the stability of the research process (Sjöström &

Dahlgren, 2002;). The aims of the studies were, after careful screening, decided

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48

to be appropriate to the phenomenographic (Study I) and CIT (Study II)

approaches of qualitative research (Flanagan, 1954; Sjöström & Dahlgren

2002). By having frequent meetings of the research group during the analysis

process a high inter-subjective agreement was reached. The interview guides

and all steps in the analysis were described carefully to enable replication of the

studies.

Confirmability refers to the objectivity of data and that the findings reflect the

participants’ statements in a truthful way (Holloway & Wheeler, 2009). To

reach confirmability, the objectivity of data was taken into account throughout

the whole research process. Pre-understanding is described as having beneficial

effects in the chosen qualitative approaches (Flanagan, 1954; Marton & Both,

1997) However, the research team had a continuous awareness of that pre-

understanding can affect the objective understandings in the collection and

interpretations of data. The researchers with experience of qualitative research

continuously contributed with their objective methodological perspectives.

Additionally, the accompanying quotes in studies I and II made it possible to

evaluate the relevance of the findings.

Transferability means the extent to which the audience may generalize the

results to their own context (Holloway & Wheeler, 2009). Only some of the

studied care units involved enrolled nurses in routines of assessing pain, and

few physicians had experience of using pain scales. This explained the choice of

a purposeful sampling in study I although a strategic choice is the preferred

method of including informants (Flanagan, 1954; Marton & Booth, 1997).

It is possible to transfer phenomenographic and CIT findings to similar settings,

bearing in mind that humans vary in their way of experiencing a phenomenon,

which means that further perceptions and critical incidents may exist (Flanagan,

1954; Marton & Booth, 1997). The fact that the participants in Studies I and II

represented three professions with varying responsibilities from six surgical and

orthopaedic settings at four different hospitals was considered to increase the

ability to describe a wide perspective of pain assessments.

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49

Validity issues (Studies III, IV)

The statistical validity refers to the choice of statistical analyses in relation to

collected data (Kimberlin-Winterstein, 2008). Pain intensity is the most

clinically relevant dimension of the pain experience, regardless of the nature of

pain, and assessments should be based on self-reports (Hjermstad et al., 2011).

To ask patients to convert their pain into an NRS score however involves

various threats to the statistical validity due to the fluctuation of postoperative

pain and individual interpretations of the NRS (Wolrich, et al., 2014). This

means that exact scoring is not possible. Therefore, the statistical rationale was

based on the perspective that self-rated pain represented by numerical scores

provides more valid results when analysed as ordinal data. Furthermore, the

sample size in study III limited the possibilities to utilize the full range of NRS

due to the skewed distribution of data. Because of the low proportion of patients

scoring NRS 7-10 in study III, the sample size in study IV was increased.

The internal validity refers to the degree to which the results are free from

uncontrolled factors i.e. to ensure that instruments measures what they are

supposed to measure (Polit & Beck, 2017). The healthcare professionals’ busy

environment, theoretical knowledge and clinical experiences of using the NRS

could have had effects on the quality of patients self-rated pain scores in

measure I (III; IV). However, these circumstances reflect the clinical reality.

The questionnaires were constructed for Studies III and IV (Appendix 1, 2). No

extensive testing was made, which may have affected the validity and reliability

negatively. However, the questions of retrospective pain used in this thesis

followed guidelines (APS, 1995; Gordon et al., 2005, Brantberg & Allvin,

2016) and were based on the thoroughly validated NRS that is considered

reliable for the measuring of pain intensity (Williamson & Hoggart, 2005;

Hjermstad et al., 2011). Furthermore, the internal response rate was high for

both questionnaires, which indicated that the questions caused only minor

difficulties as regards answering.

The external validity refers to the extent of generalizability of research. It means

the transferring of results to other settings or samples (Polit & Beck, 2017), in

this case to healthcare professionals caring for patients undergoing major

orthopaedic or general surgery in Western countries. There are cultural and

gender differences in how pain is experienced and expressed that inevitably

affect the actions needed to take in the pain assessment situation (Kvachadze et

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50

al., 2015). However, the NRS is described to apply to different cultures and

settings (Williamson & Hoggart, 2005; Hjermstad et al., 2011). The variation of

the enrolled patients in studies III and IV in terms of sex, age, education,

comorbidity, different types of surgery and postoperative pain management,

together with the high prevalence of patients with preoperative analgesia such

as opioids contribute to the external validity. Also, the fact that data was

collected in clinical settings in which the pain measures (mode, md and

maximum) were intended to be used without having to implement new routines

on pain assessments increased the generalizability to other settings.

Inter-rater reliability refers to the equivalence of scores obtained by an

instrument (Polit & Beck, 2017); in this case the NRS, when used by different

persons. One can assume that patients’ willingness to report truthful pain scores

is associated with the healthcare professionals’ pain assessment performance.

Therefore, the designs (III, IV) encouraged the collection of frequent patient

self-rated pain scores. Furthermore, the limit of four pain scores in analyses was

set to achieve reliable individual measures (mode, md and maximum) that

corresponded to patients’ experienced pain intensity.

The reliability of a test-retest design depends on the timing of the second

measure (Kimberlin & Winterstein, 2008). Memory of pain is associated with

individual sensory-affective and psychological factors and may change over

time (Khoshnejad, Fortin, Rohani, Duncan, & Rainville, 2014). However,

patients are likely to give reliable reports of pain intensity for the previous 24

hours (Breivik, Borchgrevink, Allen, Rosseland, Romundstad, Hals, Kvarstein,

& Stubhaug, 2008). Conclusively, a short time-frame between the measures in

studies III and IV was deemed to limit the effects of patients’ possible memory

disorders.

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Aspects of the results

The main objective of this thesis was to explore healthcare professionals’ use of

pain scales in pain assessments. The results are discussed in relation to the main

perspectives that became evident in healthcare professionals clinical utilization

of pain scales. The discussion starts with the organizational perspective,

followed by the collaborative and individual perspectives.

Pain assessment– the organizational perspective

The findings in studies I and II showed that organizational support from clinical

management such as care goals, guidelines, scheduling allowing continuity in

care, and well-designed EMR has an impact on how healthcare professionals

perceive the clinical use of patients’ self-rated pain scores. These findings are

supported by results from research areas involving organizational routines

(Becker 2004; Martin et al., 2010), perioperative care (Spanjersberg et al., 2011,

Liu et al., 2016) and pain management (Gordon et al., 2005). Knowledge from

these areas concludes that set goals, high quality guidelines and knowledge of

each other’s responsibilities are considered to facilitate fruitful collaboration.

Furthermore, standards of management include well-functioning organizational

routines and information systems (Martins et al., 2010). The results from studies

I and II showed that the quality of pain assessment guidelines in the studied

settings varied, which consequently meant that the healthcare professionals’

routines when assessing pain were partly based on their individual knowledge.

Additionally, the findings of restricted possibilities to monitor patients’ pain

scores at rest and during activity in EMR (I) confirm earlier findings of

difficulties in documenting care processes in EMR (Saranto & Kinnunen, 2009,

Stevenson et al., 2016). Stevenson et al, (2016) found that the quality of

monitoring of vital signs was increased by choosing paper protocols despite

access to EMR. Fragmented documentation may lead to verbal transfer of

patient information which implies a risk that information is lost (Chard &

Makary, 2015). As a consequence, the frequent information transfers in

postoperative care settings are a major risk to quality of care (Braaf et al.,

2015). Conclusively, these findings suggested that there was a need to find a

summarized measure from patients self-reported pain scores to monitor in

medical records.

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52

The explored daily average (mode and median) pain intensity measures from

patients’ self-rated pain scores at rest and during activity was shown to possess

acceptable reliability (III, IV). The findings (IV) revealed the need for frequent

high quality pain assessments (4-9 ratings) irrespective of level of pain

intensity, to ensure the quality of reports of patients’ pain in medical records.

The average measures at rest and during activity were more thoroughly

investigated (IV) than the maximum measure. Therefore, the average measures

should preferably be used together in reports of patients’ summarized daily

pain. Long clinical experience of postoperative pain in postoperative settings

inspired the development of both the mode and the median measures. The mode

measures would be most applicable if patients self-reported pain scores were

monitored using paper monitoring sheets. In a busy clinical context, it is easy to

quickly obtain an overview of what score is the most common. However, the

development of the monitoring of patient-reported outcomes in electronic

devices is ongoing (Lavallee, et al., 2016). Therefore, when it is possible to add

a calculator function to the EMR application, the median measures are deemed

more applicable to the EMR.

Healthcare professionals awareness that regular monitoring of patients’ self-

rated pain scores could be used for quality measures was limited (I). There are

various suggested patient-reported pain measures for the evaluation of quality

of pain management (Gordon et al., 1995; Gordon et al., 2005 and Gunningberg

& Idvall 2007; Rothaug et al., 2013). However, recent research has identified

the need for early identification of patients with persistent severe pain after

surgery (Althaus et al., 2014; Radnovich et al., 2014). Additionally, the busy

clinical working environment means that organizational routines should create

value, i.e. “provide the best patient outcomes (quality) using the least available

resources” (Samuels & Manworren 2014). Daily monitoring of average pain

measures in the EMR until pain resolves could constitute an approach to meet

these calls for patient-reported outcome measures.

Severe pain is evident not only after major, but also after minor surgery

(Gerbershagen et al., 2013), which implies a wider field of use for the average

pain intensity measures. Additionally, surgical procedures are being

continuously developed, which suggests that improved understanding of pain

resolution is continuously required (Althaus et al., 2014; Gerbershagen et al.,

2013). However, the time spent receiving hospital care after surgery has in

general become short, which indicates the need for continuing to report pain

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53

from home, regardless of the type of surgical procedure. Patients’ willingness to

share their symptom experiences by using new technologies is found to be high,

especially if the information is used in dialogue with the treating provider when

needed (Lavallee et al., 2016). However, technological, and logistical barriers

need to be surmounted before the summarized average measures can be further

investigated in clinical practice.

Pain assessment– the collaborative perspective

The findings in studies I and II confirmed that healthcare professionals

perceived patients’ self-rated pain scores to be a valid common language when

patients’ pain was communicated between healthcare professionals. The pain

scores were considered to help avoid misunderstandings in information transfer

because of differences in the valuation of the descriptive meaning of words. The

transfers of care information in surgical settings are complex due to the frequent

transport of patients through different departments along the perioperative path

(Braaf et al., 2015). The effects of using patients’ monitored pain-scores at

handovers are sparse evaluated. The healthcare professionals described that

patients’ frequent monitored pain scores in medical records could motivate pain

management actions (II) which is in line with Ene et al. (2008) who

demonstrated that the consequence of excluding of patients' pain scores could

result in less use of analgesics. The handover is defined as a “multi-functional

communication process where individual and collaborative clinical knowledge

is produced” (Buus, Hoeck, & Hamilton, 2016), ideally resulting in improved

prioritizing of care as well as increased patient satisfaction (Anderson, Malone,

Shanahan, & Manning, 2015). When healthcare professionals choose bedside

handovers, the patient perspective is available in the transfer of information

because of the possibility for verbal, written or visual communication

(Anderson et al., 2015). However, questions regarding the need for educational

efforts in communication have been raised because patients’ active involvement

in decisions has been shown to be lower than expected (Anderson et al., 2015;

Liu et al., 2016). From the healthcare perspective, an identified power

imbalance in between healthcare professionals (Linell & Luckman., 1991;

Foronda et al., 2016) and their professional authority can explain patients’

hesitation regarding active involvement in care (Joseph-Williams, Elwyn, &

Edwards, 2014). Clinical implementation of the developed daily average NRS

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measures (III, IV) may constitute important motivating keys for healthcare

professionals to encourage patients to communicate pain.

The healthcare professionals described that patients’ frequent monitored pain

scores in medical records had a supporting function when patients’ analgesia

needs had to be explained to each other (II). This is in line with Foronda et al.’s

(2016) conclusion that healthcare professionals who use a structured

communication style are better equipped to overcome communication barriers.

Foronda et al. (2016) identified communication barriers between different

professions as being caused by different training. In general, physicians are

trained to be highly objective and specific, while nurses speak in a more

narrative style. To achieve mutual understanding between healthcare

professionals, structured transfer of patient information is recommended

(Anderson et al., 2015; Chard & Makary, 2015). The structured use of patients’

self-reported outcome measures may constitute a common base in dialogues.

However, healthcare professionals also stated that continuous sharing of clinical

experiences at ward-rounds and handovers was highly applicable to

postoperative pain due to the various dimensions of pain (II). The findings

reflected a problem-solving working climate when patients’ pain-scoring was

difficult to understand, which is in line with the concepts of inter-professional

collaboration (Martin et al., 2010) and relational coordination (Havens et al.,

2010), highlighting the benefits of considering different professions’

perspectives in problem-solving.

Healthcare professionals found that patients’ pain-scoring sometimes

mismatched their behavioural pain expressions and therefore hesitated to use

pain scales (I, II). On the other hand, the findings (I) also revealed that the use

of pain scales could find patients who did not talk about their pain because of

various barriers, e.g. pre- or postoperative cognitive impairments, side effects

from analgesia, fears or language deficiencies. The understanding of patients’

pain experience is important because of its association to the initial ability to

recover (Allvin et al., 2008). The increased evidence of associations between

persistent postoperative pain and prolonged recovery has highlighted the

importance of reducing postoperative pain intensity in the first 24 hours after

surgery. The initial pain resolution is considered easy to clinically identify

(Althaus et al., 2014; Fletcher et al., 2015). However, patients’ preoperative

chronic pain levels are important to bear in mind (Pogatzki-Zahn et al., 2015). It

might not be fair to expect to reach pain scores far below preoperative levels

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55

although the results from the orthopaedic group (IV), consistent with the results

of Pogatzki-Zahn, Kutschar, Nestler, & Osterbrink (2015), showed that patients’

preoperative average pain levels could be decreased on the first postoperative

day. Knowledgeable healthcare professionals and multi-modal postoperative

pain management strategies in the first days after surgery can explain these

effects (Pogatzki-Zahn et al., 2015). Nevertheless, patients with persistent high

levels of postoperative pain, despite multi-modal pain management and no signs

of post-surgical complication, should be further examined for neuropathic pain

conditions (Radnovich et al., 2014). The findings (II) showed that when pain-

competence outside the surgical team was needed, the organization of acute

pain services contributed with their pain assessment and management

competences. Unfortunately, the Acute Pain Service (APS) provision is highly

variable and not available in every hospital (Duncan et al., 2014; Meissner et

al., 2015)

Pain assessment– the individual perspective

The findings in studies I and II confirmed earlier described benefits of patients’

self-rated pain scores in the aim of controlling patients’ postoperative pain, i.e.

keeping patients’ pain scores low (Mc Caffrey, 1997; Lynch, 2001; Gordon et

al., 2005; Layman Young et al., 2006). However, healthcare professionals’

perceptions of the professional responsibility to balance pain relief with

potential side effects and to be observant for any post-surgical complications

were also identified (II). To avoid fatal side effects from pain management, the

importance of ensuring proper understanding of patients’ pain at times when

patients’ pain scores “mismatched” observed pain behaviours was claimed (I,

II). Active assurance meant to observe patients’ pain-related behaviours during

care and to ask for patients’ descriptions of pain (I, II), which is in line with

earlier findings of nurses’ pain assessment behaviours (Kim et al., 2006;

Lauzon-Clabo, 2007). However, self-perceived lack of experience and

knowledge of how to handle mismatching pain scores with observed behaviours

created uncertainty (I, II). Research on clinical reasoning gives solid

confirmation of the importance of both individual knowledge and professional

experience in care decisions (Norman, Monteiro, Sherbino, Ilgen, Schmidt, &

Mamede, 2017). Clinical reasoning means to assess a situation by systematic

gathering and checking of information accuracy and reliability, and to identify

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56

missing information (Lee, Lee, Bae, & Seo, 2016). Beyond the knowledge of

surgical care, assessment and management of pain the numerous patient-related

communication barriers (II, Jacobsen, Mölrup, Christrup, & Sjögren, 2008; van

Dijk et al., 2016) suggest that healthcare professionals in each assessment

situation need to choose applicable communication approaches to be able to

collect appropriate information from patients in pain.

Healthcare professionals were aware of the benefits of obtaining mutual

understanding by listening to the patients’ perspective of pain; however,

perceived lack of time was described as a reason why communication was

reduced to leading questions (II). Paying attention to patients’ individual verbal

and behavioural expressions, and needs by listening to their stories is in line

with central principles of person-centred care. To give patients time has been

shown to have strong associations with patients’ perceptions of quality of care

and person-centeredness (Edvardsson, Watt, & Pearce, 2016). Schwenkglenk et

al., (2014) finding of that patients’ perceive that pain intensity is subordinated

to healthcare professionals’ attention to pain supports the importance of taking

time to communicate. A complicating factor is to find those patients who adjust

their NRS scoring in accordance with anticipated consequences such as

desired/undesired analgesia administration and possible judgements by

healthcare professionals (van Dijk et al., 2016). Therefore, in addition to the

collection of pain scores, the understanding of patients’ experiences of analgesia

and postoperative recovery is most important as patients’ attitudes and fears can

be revealed. Moreover, by informing about the effects on recovery such as the

decreased risk of post-surgery complications and giving patients time to talk

about their situation, patients “power” to influence decisions increases (Joseph-

Williams et al., 2014). However, busy working conditions and lack of

continuity in scheduling were described as reasons why collected information

was at times restricted to what analgesia had been given during the last few

hours (II). These findings are confirmed by earlier findings of effects from time

constraints on the inclusion of new evidence in routines (Becker, 2004).

Without access to the history of pain, patients’ pain scores might be

misunderstood. Van Dijk et al., (2016) found that patients might assign a low

score on the NRS because they do not want to be perceived as weak or bother

busy nurses. On the other hand, patients with chronic pain may assign a higher

score on the NRS compared to patients with no history of chronic pain (Wolrich

et al., 2015). This implies that patient’ attitudes, fears and preoperative pain

experiences can explain their pain-scoring. Consequently, if patients’

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experiences remain unknown it could mean that healthcare professionals’ own

interpretation of the NRS may become dominant in clinical reasoning instead of

finding out the the actual significance of the patients’ NRS pain scores.

There were also healthcare professionals who described passive pain assessment

approaches; observations without reflection (II). These healthcare professionals’

habits were dominated by the reliance on long clinical experience and “sensing

pain” when giving care to patients (I). Their observational skills of non-verbal

pain behaviours become important, when a dialogue was not possible because

of various verbal communication barriers. Various observational-behavioural

instruments have been developed to assess pain in patients with severe dementia

(Hadjistavropoulos et al., 2014). These instruments are in general considered

too extensive in the postoperative setting. However, knowledge of the items can

be useful to less experienced healthcare professionals when patients, after

surgery, have limited cognitive resources to communicate pain also due to other

reasons than dementia. However, the experienced healthcare professionals who

preferred to observe verbally communicating patients’ pain behaviours instead

of asking about their pain experience (I) might be more likely to avoid pain

scales despite the implementation of new pain assessment routines. Overall

social norms in the clinical setting (Lauzon-Clabo et al., 2007) in combination

with established routines and habits are difficult to change because of the

comfort of repeating known procedures automatically (Nilsen et al., 2012).

Successful breaking of established habits is known to require responsibility

from leaders (Rytterström et al. 2011) and actions such as placed reminders and

targeted evaluations (Nielsen et al., 2012). Motivation to change also seems to

arise when care routines are in harmony with healthcare professionals’

individual perceptions of care (Rytterström et al., 2011). The findings in studies

I and II suggest that healthcare professionals with deeper knowledge i.e.

understanding of communication put more effort into motivating patients to

report pain and trying to understand patients’ pain scoring. Therefore, deeper

knowledge about communication and barriers affecting patients’ self-rated pain

scores, in addition to new motivational organizational routines have to be

considered when implementing the average pain measures (III, IV) to be sure of

the quality of these measures.

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Theoretical reflection

This thesis demonstrates the healthcare professionals’ perspective on the

utilization of pain scales in postoperative care settings after major surgery.

Healthcare professionals have so far mainly focused on the use of pain scales in

the pain assessment situation. It has historically been difficult to explain why

healthcare professionals’ documentation of patients’ self-rated pain scores is

mainly dependent on individual habits. Fragmentary documentation means that

further collaborative use of patients’ pain scores in the team and in the transfer

of pain information risks becoming restricted to one shift as turnover of staff

during patients’ hospital stay is high. These consequences can be explained by a

high workload in acute settings, patients’ various pain expressions and the

difficulty synthesising many pain scores into one reliable measure that is easy to

use in the transfer of pain information.

Based on the findings from this thesis it can be argued that the use of pain

scales is dependent on multiple perspectives to be fully utilized. The model

(Figure 8) represents important key components in healthcare from the

organizational, collaborative and individual perspectives without any

hierarchical order.

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Figure 8. A model of key components needed to achieve a structured use of pain scales

in postoperative clinical settings, from the organizational, collaborative and individual

perspectives without any hierarchical order

The organizational perspective

Organizational supportive strategies such as the quality of set goals, local

guidelines and documentation devices affect cultural norms regarding attention

to patients’ postoperative pain experience. Also, the attention to the patient

perspective i.e. current pain experience and history of pain, is affected by the

different healthcare professional’s responsibilities in postoperative pain

assessments. Healthcare professionals’ opportunities to work evidence based is

one component in an organizations attention to quality, in this case

postoperative pain. The culture of measuring clinical outcomes by the use of

patient-reported outcome measures is embraced in the development of

The organizational perspective

- the attentiveness to pain

- the quality of guidelines

- the quality of documentation devices

The individual perspective

- the knowledge of pain/analgesia

- the quality of communication

- habits when assessing pain

The collaborative perspective

- the quality of collaborative routines

- the knowledge of available networks

- the quality of information transfer

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knowledge-based organizational routines. However, in order to conserve care

resources in the acute busy clinical context, postoperative pain assessments

should preferably be discontinued when postoperative pain has been resolved.

The collaborative perspective

The quality of collaboration between healthcare professionals depends on both

structural and relational factors. Collaborative structures such as integrated

documentation and joint enrolled nurse/nurse/physician meetings enable

understanding and trusting relationships between different healthcare

professions. A good relationship in the team around the patient is shown to have

a strong influence on quality of care. Also, the knowledge of and openness to

competences outside the team contribute to care. By providing a common pain

discourse i.e. patients’ pain scores, potential hierarchical complexities between

different healthcare professions can be bridged. Additionally, the daily

summarized average measures at rest and during activity could provide a simple

approach for the monitoring of patients’ pain scores in medical records until

pain resolves, and could thereby constitute a basis for clinical reasoning,

decisions and transfer of pain information between healthcare professionals.

The individual perspective

The quality of healthcare professionals’ routines in the actual setting is, in

addition to past history of organizational routines related to social norms,

individual knowledge and clinical experience. Knowledge of how to administer

balanced analgesia safely without masking potential post-surgical complications

is related to perceived quality of care from the perspective of healthcare

professionals’. The NRS facilitates rapid evaluation of postoperative pain and

constitutes the basis of treatment algorithms; however, the selection of

treatment alternatives should also include consideration of pain quality,

location, duration, and impact on recovery when needed. Patients’ age, sex,

psychosocial, cultural, and religious features and comorbid health conditions are

also important to consider. Furthermore, healthcare professionals’ use of pain

scales in assessment of patients’ pain demands communication about patients’

individual interpretations of the NRS scores, including the definition of worst

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possible pain. Communication skills are needed to be able to instruct and

motivate patients to rate their pain and describe their history of pain experiences

and expectations. With a dialogue, much knowledge can be transferred between

healthcare professionals and patients. However, healthcare professionals with

established pain assessment habits that exclude patients’ self-rated pain and

written information transfer of pain could have an impeding impact on further

use of patients’ self-rated pain. Instead of repeatable habit formations when

assessing pain, a multi-dimensional communication approach was found

necessary to understand each patient’s pain expressions, desires and needs.

The organization, collaboration and individual perspectives have an overall

impact on healthcare professionals’ utilization of patients’ self-rated pain

scores. The collaborative working climate is related to the structure of

organization, accurate documentation devices, and overall attention to pain

management. Furthermore, the use of pain scales includes awareness of the

different dimensions of pain and patients’ various interpretations of the

conversion of pain intensity into a numerical scale.

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Conclusions and clinical implications

This thesis adds new insights into how healthcare professionals utilize pain

scales in their assessments of patients’ postoperative pain. Additionally, a new

approach to improve the utilization of patients’ self-reported pain scores in

clinical decisions was determined. The conclusions and clinical implications are

described in relation to the organizational perspective, followed by the

collaborative and individual perspectives.

The organizational perspective

Conclusions

Healthcare professionals’ use of pain scales was related to the attention

to pain by the management, in local guidelines, EMR and monitoring

records.

The NRS average pain measures (mode/median at rest and during

activity) from patients’ self-reported pain on postoperative day 1 gave a

reliable picture of patients’ postoperative pain at rest and during

activity.

The significantly higher pain levels on activity confirmed the relevance

of structured clinical measuring of pain both at rest and during activity.

Clinical implications

The findings indicate that healthcare professionals’ attention to patients’

pain should be clearly stated by ward management and in written local

guidelines.

Patients’ self-reported daily average pain measures may also encourage

clinical work on identifying resolution of pain in different surgical

procedures, which consequently may contribute to further

improvements of surgery-specific pain management routines.

In the future, persistent high average pain scores may also be used as an

important tool for the clinical prediction of post-surgical chronic pain

conditions.

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The collaborative perspective

Conclusions

The use of pain scales increased the quality of information

transfer of pain by providing a common language. However, the

use of pain scales at times demanded collaborative reflections on

the differences between healthcare professionals and patients’

interpretation of pain scores.

The handovers, ward-rounds and collaboration with pain

specialists offered important occasions for the exchange of

clinical experiences.

Clinical implications

The findings confirm that patients self-reported pain scores could

provide a common language in written and verbal transfer of

patients’ pain information between healthcare professionals

during daily care duties and between units.

The use of daily average pain intensity measures, in line with

person-centred care, ensure the patient’s perspective is considered

in clinical reasoning, decisions and transfer of pain information.

The individual perspective

Conclusions

The use of pain scales when assessing pain varied greatly due to

individual established habits, and perceptions of patients’ needs and

barriers.

The use of pain scales facilitated the understanding of pain; however,

skilful communication was required to discover the significance of

patients’ pain scores.

Healthcare professionals’ goal in pain management was to balance

patients’ needs with safe analgesia administration.

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Clinical implications

The findings support the view that patients’ self-rated pain, when

individually tailored can support clinical reasoning and decisions on

pain management. However, the potential risk of healthcare

professionals’ and patient’s divergent interpretations of pain scores can

cause misunderstandings.

Healthcare professionals need to be aware of barriers concerning

patients’ ability and willingness to report pain.

Healthcare professionals’ motivation to include patients’ self-rated pain

in assessments of pain could be enhanced by the transition from the

asking of questions to the introducing of “two-way dialogue”

communication with patients. By listening to the patient’s own

perspective of pain, knowledge useful for clinical reasoning and

decisions can emerge.

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Future research

Based on the results of this thesis the following future research is suggested:

The link between the NRS average measures at rest and during and

recovery, based on patients’ self-rated pain scores, needs to be clarified

and the clinical utility of these average pain intensity measures in

decisions on pain management needs to be explored.

Further exploration of motivational factors and adequate work

conditions association with performance of pain assessments is needed

to understand their effects.

An exploration of how patients’ conversion of pain into numerical

scales varies depending on their obtained knowledge and experiences

during the postoperative period is needed to understand potential

variations over time.

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Summary in Swedish

Introduktion

Förekomst av postoperativ medelsvår till svår smärta de första dagarna efter stor

kirurgi är hög. Medvetenheten om att patienters lidande av smärta inte bara

påverkar hälsa ur ett kort perspektiv utan också riskerar en hälsopåverkan ur ett

långt perspektiv har ökat. De senaste årens snabba utveckling mot korta

vårdtider innebär dock att tiden att lära känna patienters behov blir allt kortare.

Tidigare forskning beskriver bedömning av smärta som komplex.

Smärtupplevelsen betraktas som en personlig upplevelse kopplad till kön,

värderingar samt till upplevd hälsa. Internationella riktlinjer anger att

systematisk mätning av patienters självskattade smärtintensitet hittills är det

mest kliniskt relevanta sättet att följa patienters postoperativa smärta. Den

numeriska skalan, Numeric Rating Scale (NRS 0-10), är en rekommenderad

smärtskala i de flesta kliniska sammanhang. I svensk vård är det

undersköterskor, läkare och sjuksköterskor som huvudsakligen vårdar patienter

efter genomgången kirurgi. För att uppnå vårdkvalitet är sjukvårdspersonalens

individuella roller lika viktiga som samordningen mellan rollerna. Forskning

visar att smärtskalor används i begränsad omfattning av sjukvårdpersonal vilket

har väckt frågor om smärtskalors bidrag till att identifiera och förstå

patienternas smärta.

Vidare är det visat att dokumentation av smärta är ostrukturerad, vilket kan

påverka behandlingseffekter och patientsäkerhet. Tidigare forskning beskriver

att kliniska beslut baserade på patienters självrapportering av smärta gynnar

patienters delaktighet och därmed säkerhet. Dock behövs motiverande strategier

för att förbättra klinisk användning av patienters självskattade smärta. Det

övergripande syftet med denna avhandling var därför att beskriva den kliniska

nyttan av patienternas självskattade postoperativ smärta efter större kirurgi

utifrån sjukvårdspersonalens perspektiv.

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Design och metod

Avhandlingen bygger på kvalitativa och kvantitativa studier. De kvalitativa

studierna beskriver (I) hur vårdpersonal uppfattar användningen av smärtskalor

i postoperativ vård och (II) genom kritiska incidenter vilka vårderfarenheter

sjukvårdspersonal har och vilka åtgärder de vidtar vid bedömning av

postoperativ smärta. Deltagare i studie I och II var kliniska verksamma

undersköterskor, sjuksköterskor och läkare med erfarenhet av smärtskalor i

postoperativ vård. Syftet med de kvantitativa studierna var att fastställa

tillförlitligheten av dagliga genomsnittsvärden (typ- median och max) baserade

på patienters självskattade NRS värden vid vila och under aktivitet vid

beskrivning av patienternas postoperativa smärta första dagen efter stor kirurgi

(III, IV). Syftet var också att bestämma antalet NRS skattningar som behövs för

beräkning av dessa värden (IV).

Resultat

De kvalitativa resultaten bekräftade tidigare fynd av patienters självskattade

smärta bidrag till förståelse av postoperativa smärta och därpå följande kliniska

beslut. Organisatoriska rutiner, dokumentationsmöjligheter, kunskap, klinisk

kompetens, kontinuitet i vården, samarbete, tid och individuella vanor var

vårdrelaterade faktorer som påverkade sjukvårdpersonalens användning av NRS

(I, II). Patientrelaterade bidragande faktorer till smärtskattning med NRS var

patienters förmåga och villighet att kommunicera, medan oförmåga eller ovilja

att kommunicera, inkonsekvens mellan verbal kommunikation och observerat

beteende, beskrevs vara barriärer (II). Kunskap om olika

kommunikationsstrategier i samband med smärtskattning kunde överbrygga

dessa patientrelaterade barriärer (I, II).

Resultat från de kvantitativa studierna (III, IV) visade hög tillförlitlighet för de

dagliga genomsnittvärdena: typ och median vid vila och aktivitet.

Rankkorrelationer för individuella medianvärden, baserat på fyra skattningar

var i jämförelse med patienters i efterhand självskattade genomsnittliga smärta

hög och förstärktes med ökat antal, upp till nio, skattningar. Svensson analyser

påvisade en individuell variation inom det förväntade. Vidare gav resultaten en

signifikant systematisk gruppförändring som visade att de beräknade typ- och

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medianvärdena, särskilt när det gäller smärta i vila, generellt var lägre än de

genomsnittliga värden som patienterna angav i efterhand.

Kliniska implikationer

Ur ett organisatoriskt perspektiv tyder resultaten på att klinikledning

samt lokala riktlinjers uppmärksamhet på smärta har betydelse för

användning av smärtskalor. Uppföljning av patienters dagliga

genomsnittliga postoperativa smärtvärden kan uppmuntra till kliniskt

arbete med att identifiera normal återgång av smärta vid olika

kirurgiska ingrepp, vilket därmed kan bidra till ytterligare förbättringar

av ingrepps specifika smärthanteringsrutiner. I framtiden kan

kvarstående höga genomsnittliga smärtvärden förslagsvis även

användas som en viktig del i bedömning av för postoperativa kroniska

smärttillstånd.

Ur ett kliniskt samarbetsperspektiv bekräftar resultaten att patienters

självrapporterade smärta skulle kunna innebära ett gemensamt skriftligt

och muntligt språk i rapportering mellan vårdpersonal och enheter.

Användning av dagliga genomsnittliga NRS värden är i linje med

personcentrerad vård, vilken innebär att säkra patientens perspektiv i

kliniska resonemang och beslut.

Ur ett individperspektiv, vårdpersonalens möte med patienten, stödjer

resultaten användning av patientens självskattade smärta vid

smärtbedömning för att underlätta kliniska resonemang och beslut.

Däremot finns en potentiell risk för att sjukvårdspersonalens och

patienters olika tolkningar av NRS orsakar missförstånd. Risk för

missförstånd skulle dock kunna reduceras genom att frångå enkelriktade

frågor till att övergå till en dialog där patienter får utrymme att berätta

om sin situation. Genom att lyssna till patienters perspektiv på smärta,

kan klinisk kunskap generas, användbar för kliniska resonemang och

beslut.

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Slutsatser

Sammanfattningsvis, stödjer hälso- och sjukvårdpersonal tidigare beskrivna

gynnsamma effekter av patienters självrapporterade smärta. Dock bistår

nuvarande vård inte till ett strukturerat utnyttjande av patienters självskattade

smärta. Med hjälp av dagliga genomsnittliga NRS smärtvärden kan patienters

smärta följas till dess att smärtan har lagt sig. Tack vare dessa mätvärdenas

enkla egenskaper, kan dessa värden också bli viktiga patientrapporterade

kvalitetsmått och kan därmed utgör ny drivkraft till att öka användningen av

smärtskalor i kliniskt arbete.

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Acknowledgements

As a qualified nurse with long clinical experience it is a positive challenge to

undertake PhD studies. Curiosity and a stubborn mind are human characteristics

that were the driving force in my research. However, without access to senior

researchers and supporting work and social networks this thesis would not have

been completed.

Everything began with an idea on how to follow patient’s postoperative pain

trajectory before hospital discharge. Thanks to our dear colleague Marianne

Lindbladh-Fridh, Kerstin Eriksson and I started research. Marianne gave

continuous and invaluable support and encouraged future studies. Kerstin has

been my supporting companion and the best friend one can have.

Anders Broström, our main supervisor introduced us to further research with

great patience. His solid knowledge of research, sense for details and

conclusions and everything in between has meant a lot to our progress. Our

senior co- supervisor Bengt Fridlund contributed to the scientific structure of

this thesis with his extensive and solid knowledge of research. Along the way,

our second co-supervisor Kristofer Årestedt became a “team” member. His

sense for logical reasoning and his skills in the world of statistics have inspired

new ways of thinking. Our team meetings became very collaborative; normally

we left the whiteboard full of future plans. I am very thankful to you all for the

constructive support during these years. I will miss this time in my life.

The production of a thesis also depends on the opportunities to collect data.

Thanks go to the managers of the included ward units who gave time to the

designated and dedicated research nurses to organize the collection of data.

Thank you to all the health care professionals and patients who shared their

experiences. Your participation contributed to the results of this thesis.

Thank you to Futurum, the Academy for Health and Care, County Council of

Jönköping who gave us financial support, and to their statistician, Mats Nilsson,

who with his expertise supported the analysis in study IV. Thank you also to

FORSS, the Medical Research Council of Southeast Sweden who supported us

financially.

I am very thankful to the research school of health and welfare at Jönköping

University who took me on as a PhD student. The courses and seminars have

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given me a wider perspective in my research and a “platform” for further

research. Additionally, I want to thank the research coordinators, Paula

Lernståhl da Silva and Kajsa Linnarsson for their administration support.

I would also like to thank the management and colleagues at the department of

Anaesthesia and Intensive care at the County Hospital of Jönköping who have

supported and encouraged me to continue with my work.

In my life, my very special husband Göran and our children Martin and Moa

mean the world! I know that during the past years I “periodically” have had my

thoughts “elsewhere”. You have also had to listen to various conclusions from

my results…. and you will….hopefully, have to listen to more in the future!

Finally, my thoughts go to my parents.

Jönköping 2017

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5

Appendix 1 Enkät Kodnummer________

Man Kvinna Ålder _____

Ingrepp_____________________ Operationsdag __________ Klinik_________

Har du haft en smärta de sista 6 månaderna som inneburit att du dagligen tagit

smärtstillande läkemedel? Ja Nej

Om du svarat ja på frågan, vilket/vilka smärtstillande läkemedel har du använt

dagligen?

Läkemedel: _________________________________________________________________

Vilken smärtnivå har du i genomsnitt upplevt de senaste 4 veckorna? Ringa in det

alternativ som stämmer bäst för dig. 0 = ingen smärta, 10 = värsta tänkbara smärta.

I vila:

0 1 2 3 4 5 6 7 8 9 10

1. Hade du smärta?

Ja Nej om nej, fortsätt till fråga 12

2. Upplevde du någon gång att din smärtnivå hade en styrka inom intervallet 0-3?

Ja, mer än 1 timme Ja, mindre än 1 timme Nej

3. Upplevde du någon gång att din smärtnivå hade en styrka inom intervallet 4-6?

Ja, mer än 1 timme Ja, mindre än 1 timme Nej

Hade du SMÄRTA DAGEN EFTER OPERATION (Kl. 06-06)

Kryssa i det alternativ som bäst stämmer överens med din upplevelse.

I aktivitet (dagliga sysslor, gång, fritidsaktivitet):

0 1 2 3 4 5 6 7 8 9 10

6

4. Upplevde du någon gång att din smärtnivå hade en styrka inom intervallet 7-10?

Ja, mer än 1 timme Ja, mindre än 1 timme Nej

5. Har smärtan hindrat dig från att sköta din hygien och klä på/av dig?

Inte alls Delvis Till stor del Helt och hållet

6. Har smärtan hindrat dig från att röra dig i sängen?

Inte alls Delvis Till stor del Helt och hållet

7. Har smärtan hindrat dig från att vara uppe och gå?

Inte alls Delvis Till stor del Helt och hållet

8. Har du fått tränings eller mobiliseringsprogram att följa efter din operation eller

mål med hur länge du ska vara uppe ur sängen?

Ja Nej om nej fortsätt till fråga 10

9. Har smärtan hindrat dig från att utföra träningsprogrammet eller uppnå målet

med hur länge du ska vara uppe ur sängen?

Inte alls Delvis Till stor del Helt och hållet

10. Har smärta påverkat din förmåga att äta eller dricka?

Inte alls Delvis Till stor del Helt och hållet

11. Har smärta påverkat din sömn?

Inte alls Delvis Till stor del Helt och hållet

Appendix 2 Enkät studie 4 KOD ____

1. Vilket är ditt födelseland?

Sverige Övriga Norden Övriga Europa Övriga Världen

2. Med vem delar du bostad, under större delen av veckan? Du kan ange flera alternativ.

Ingen Föräldrar/syskon Make/maka/sambo/partner Andra vuxna Barn

3. Vilken är din högsta avslutade utbildning?

Har inte avslutat grundskola Grundskola eller likvärdigt

Gymnasium eller likvärdigt Universitet eller högskola

________________________________________________________________________________

Följande frågor gäller SMÄRTA och ILLAMÅENDE före operation

4. Vilken smärta har du i genomsnitt upplevt de senaste 7 dygnen?

I vila: Ingen smärta 0 1 2 3 4 5 6 7 8 9 10 Värsta tänkbara

smärta

I rörelse: Ingen smärta 0 1 2 3 4 5 6 7 8 9 10 Värsta tänkbara

smärta

5. Har du använt smärtstillande läkemedel de senaste 6 månaderna ?

Nej

Ja Om ja, hur ofta har du varit i behov av smärtstillande läkemedel?

Dagligen Några gånger i veckan Några gånger i månaden

6. Vilka läkemedel har du använt mot smärta?

7. Vilket illamående har du i genomsnitt upplevt de senaste 7 dygnen?

Inget illamående 0 1 2 3 4 5 6 7 8 9 10 Värsta tänkbara

illamående

8. Har du använt läkemedel mot illamående de senaste 6 månaderna ?

Nej

Ja Om ja, hur ofta har du varit i behov av läkemedel mot illamående?

Dagligen Några gånger i veckan Några gånger i månaden

9. Vilka läkemedel har du använt mot illamående?

Följande frågor gäller SMÄRTA från operationsområdet första dygnet efter

operation kl. 07-07

1. Vilken var den lägsta smärtan du upplevde under första dygnet efter operation?

Ingen smärta 0 1 2 3 4 5 6 7 8 9 10 Värsta

tänkbara smärta

2. Vilken var den högsta smärtan du upplevde under första dygnet efter operation?

Ingen smärta 0 1 2 3 4 5 6 7 8 9 10 Värsta

tänkbara smärta

3. Hur bedömer du i genomsnitt din smärta under det första dygnet när du vilade?

Ingen smärta 0 1 2 3 4 5 6 7 8 9 10 Värsta

tänkbara smärta

4. Hur bedömer du i genomsnitt din smärta under det första dygnet när du var i rörelse?

Ingen smärta 0 1 2 3 4 5 6 7 8 9 10 Värsta

tänkbara smärta

Vilken smärta har: Om du inte haft dessa besvär till följd av smärta anger du alternativet 0.

5. gett dig problem med att vila

Ingen smärta 0 1 2 3 4 5 6 7 8 9 10 Värsta tänkbara

smärta

6. påverkat din sömn

Ingen smärta 0 1 2 3 4 5 6 7 8 9 10 Värsta tänkbara

smärta

7. gett dig problem med att vara i rörelse

Ingen smärta 0 1 2 3 4 5 6 7 8 9 10 Värsta tänkbara

smärta

8. påverkat din aptit

Ingen smärta 0 1 2 3 4 5 6 7 8 9 10 Värsta tänkbara

smärta

9. gett dig svårighet att sköta din personliga hygien

Ingen smärta 0 1 2 3 4 5 6 7 8 9 10 Värsta tänkbara

smärta

Demografi studie 4 KOD ____

Ingrepp_______________________________ Operationsdag (år, mån, dag) _______

Man Kvinna Födelseår 19______ Ålder ______

Andra sjukdomar _____________________________________________________________

___________________________________________________________________________

Ja Nej

Rökare

Åksjuka

___________________________________________________________________________

Preoperativa läkemedel Ja Nej

Oro

Depression

Sömn

___________________________________________________________________________

Anestesi Ja Nej

Lokal

Regional

Sedering

Generell anestesi

Operationstid ________ tim ________ min

___________________________________________________________________________

Aktuell ASA klassificering:

ASA I

ASA II

ASA III

___________________________________________________________________________

Behandlingar och åtgärder postoperativ dag 1

Ja Nej Dygnsdos

Paracetamol alla beredn.former ________

NSAID alla beredn.former ________

Tramadol alla beredn.former ________

Dolcontin/Morfin tabletter ________

Oxycontin/Oxynorm tabletter ________

Opioid intravenöst ________

PCA med opioid intravenöst ________

Perifer blockad

För rökare ange ”Ja” om patient

röker dagligen.

Ange ”Ja” om patienten använder

läkemedel dagligen.

Epidural

Regional blockad

Musik

Värme

Kyla

Annat _____________________________________ ________

Ja Nej Dygnsdos

Primperan alla beredn.former _______

Zofran/Kytril alla beredn. former _______

Postafen tabletter _______

Sea-band

Annat ______________________________________________________________________

Ja Nej

Drän

KAD

V-sond

Fastande

Behandlingar och åtgärder postoperativ dag 2

Ja Nej Dygnsdos

Paracetamol alla beredn.former ________

NSAID alla beredn.former ________

Tramadol alla beredn.former ________

Dolcontin/Morfin tabletter ________

Oxycontin/Oxynorm tabletter ________

Opioid intravenöst ________

PCA med opioid intravenöst ________

Perifer blockad

Epidural

Regional blockad

Musik

Värme

Kyla

Annat _____________________________________ ________

Ja Nej Dygnsdos

Primperan alla beredn.former _______

Zofran/Kytril alla beredn. former _______

Postafen tabletter _______

Sea-band

Annat ______________________________________________________________________

Ja Nej

Drän

KAD

V-sond

Fastande

Ja Nej

Komplikation

Om ja, vad _________________________________________________________________

Vårdtid 1 2 3 4 5 6 7 8 9 >9 dagar

13

Studieprotokoll av smärta/ KOD_____ illamående/kräkning Åter från operation: kl. ________

Dokumentera under operationsdagen, postoperativ dag 1, 2 och 3 fram till kl 08.00 ___________________________________________________________________________ NRS smärta: Ingen smärta 0 1 2 3 4 5 6 7 8 9 10 Värsta tänkbara smärta NRS illamående: Inget illamående 0 1 2 3 4 5 6 7 8 9 10 Värsta tänkbara illamående ___________________________________________________________________________

Datum

Klockslag

NRS i vila

0-10

NRS i aktivitet

0-10

Illamående

0-10

Kräkning

Ja/ Nej

Dokumentation av smärta, illamående och kräkning var 4:e tim då patienten är vaken. Dokumentera med S när patienten sover. Dokumentation görs även vid genombrott av smärta, illamående/ kräkning samt vid utvärdering.