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Using mode and maximum values from the Numeric Rating Scale when evaluating postoperative pain management and recovery
Ryhov County Hospital, Jönköping.
Ryhov County Hospital, Jönköping.
Jönköping University, School of Health Science.
Jönköping University, School of Health Science, HHJ, Dep. of Nursing Science.
2013 (English)In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 22, no 5-6, 638-647 p.Article in journal (Refereed) Published
Abstract [en]

Aims and objectives: To (1) examine the clinical applicability of compiled mode and maximum values from the Numeric Rating Scale (NRS) by comparing the correspondence between patient perceptions of pain and pain values from monitoring records, as well as (2) to study the relationship between mode and maximum values and self-assessed ability for early postoperative recovery.

Background: Documentation of pain remains a problem despite recommendations of quality improvements. To examine the correlation between patient perceptions and documented pain therefore becomes important. Few have studied how pain affects recovery.

Design: A quantitative cross-sectional design was used in which 157 postoperative patients answered a questionnaire on pain intensity and recovery. A parallel examination of pain in monitoring records was conducted.

Results: A total of 57% had a mode value calculated from records between 0 and 3 on postoperative day 1 and 69% on day 2. A maximum value between 4 and 10 was found in monitoring records for 73% on day 1 and for 67% on day 2. The correspondence between mode value from monitoring records and the patients’ retrospective perceptions was 88% for NRS 0–3 and 92% between maximum value and NRS 4–10. The correlation between documented pain and retrospectively identified pain for mode value of the NRS in all (0–10) was rather weak (r = 0·37), while maximum value had a stronger correlation (r = 0·53).

Conclusion: Mode and maximum values could be used as outcome measures when evaluating postoperative pain. Pain affects recovery negatively, but more research is needed to strengthen the evidence for the use and clarify the link between pain and recovery.

Relevance to clinical practice: International organisations emphasise the importance of improving pain assessment. Mode and maximum values are easy to compile for nurses and can, together with assessments of how experienced pain levels affect postoperative recovery, improve treatment of postoperative pain.

Place, publisher, year, edition, pages
2013. Vol. 22, no 5-6, 638-647 p.
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:hj:diva-20357DOI: 10.1111/j.1365-2702.2012.04225.xPubMedID: 22946909OAI: oai:DiVA.org:hj-20357DiVA: diva2:599905
Available from: 2013-01-22 Created: 2013-01-22 Last updated: 2017-04-12Bibliographically approved
In thesis
1. Postoperative pain assessment and impact of pain on early physical recovery, from the patients' perspective
Open this publication in new window or tab >>Postoperative pain assessment and impact of pain on early physical recovery, from the patients' perspective
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Pain is a common postoperative experience. Guidelines recommend performing regular pain assessments, which include self-rated pain and additional communication to capture patients' experiences. During hospitalisation, pain intensity is found to be a vital factor influencing other aspects of an early physical recovery, and is consequently an important item in questionnaires for recovery. These tools consist of extensive questionnaires which are difficult to use in everyday clinical work. A simplified method of monitoring postoperative recovery would benefit both patients and healthcare professionals.

Aim: The overall aim of this thesis was twofold: (A) to determine the ability of extending the use of pain ratings to reflect and predict early physical postoperative recovery and (B) to describe patients’ perspectives on pain assessments.

Methods: The studies were carried out at one (I), three (IV) and four hospitals (II, III) involving general surgical and orthopaedic inpatients. Two quantitative methods were used based on data from questionnaires and medical records. They consisted of one cross-sectional study (I) and one study with repeated measures (IV). An association was sought between pain intensity and postoperative recovery on days 1 and 2 (I, IV), and prehospital data (IV). Two qualitative methods were used involving a phenomenographic (III) approach and Critical Incident Technique (IV), where semi-structured interviews were performed postoperatively and analysed inductively in accordance with the approach.

Results: An association was found between moderate/severe average pain intensity compiled from monitoring records and impact on early physical postoperative recovery on day 1 (I). Retrospective average pain intensity at rest and during activity reflected impact on recovery on postoperative day 1 (IV). Severe pain intensity at rest and during activity on postoperative day 1 predicted impact on physical recovery items on day 2 (IV). The use of the Numeric Rating Scale (NRS 0-10) was considered to facilitate communication about pain, but to involve difficulties of interpretation and place demand on healthcare professionals and care routines (II). Patients’ descriptions of their experiences when in need of describing pain indicated two main areas: patients’ resources when needing to describe pain and ward resources for performing pain assessments (III). Descriptions of their actions when they were in pain indicated two main areas: patients used active strategies when needing to describe pain or patients used passive strategies when needing to describe pain (III).

Conclusions: This thesis contributes to knowledge about the possibility of using patients' self-rated average pain intensity to reflect early physical postoperative recovery on day 1 and to predict recovery on the following day. The pain scale gave patients and healthcare professionals a shared vocabulary, which facilitated communication. Furthermore, dialogue during pain assessments was described as critical in ascertaining whether pain intensity had an impact on different aspects of physical recovery. Environmental factors such as the attitude of healthcare professionals, workload and staffing influenced how pain assessments were performed.

Place, publisher, year, edition, pages
Jönköping: Jönköping University, School of Health and Welfare, 2017. 77 p.
Series
Hälsohögskolans avhandlingsserie, ISSN 1654-3602 ; 080
Keyword
pain assessment, pain intensity, pain scale, physichal recovery, postoperative care
National Category
Nursing
Identifiers
urn:nbn:se:hj:diva-35346 (URN)978-91-85835-79-9 (ISBN)
Public defence
2017-05-10, Forum Humanum, School of Health and Welfare, Jönköping, 13:00 (English)
Opponent
Supervisors
Available from: 2017-04-20 Created: 2017-04-10 Last updated: 2017-04-12Bibliographically approved
2. The clinical utility of patients’ self-rated postoperative pain after major surgery – the perspective of healthcare professionals'
Open this publication in new window or tab >>The clinical utility of patients’ self-rated postoperative pain after major surgery – the perspective of healthcare professionals'
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The Numeric Rating Scale (NRS) is suitable in postoperative settings, yet, the implementation has shown varying results. This has raised issues about the pain scales contribution to the identifying and understanding of pain. The aim of this thesis was to describe the clinical utility of patients’ self-rated postoperative pain after major surgery from a healthcare professional perspective.

The aim of study I and II was to describe healthcare professionals’ perceptions of the use of pain scales, and to through considering critical incidents describe care experiences and actions taken by healthcare professionals’ when assessing pain. Participants in study I (N=25) and II (N=24) were enrolled- registered nurses and physicians with clinical experiences of pain scales. The aims of study III and IV were to determine the clinical applicability of NRS mode- and maximum- measures, and the NRS mode- and median measures at rest and during activity based on patients self-rated pain. The aim in study IV was additionally to determine the number of NRS ratings needed for the calculation of these measures. The number of surgical and orthopedic patients who completed study III were: n=157 and study IV: n=479.

Study I and II confirmed earlier findings of patients’ self-reported pain scores as a facilitator in the understanding of their postoperative pain. Organizational routines, documentation devices, clinical competence, continuity in care, collaborative actions, time, and individual routines were healthcare related factors affecting the use of pain scales (I, II). Patient-related facilitating factors were patients’ ability and willingness to communicate pain, while disability and unwillingness to communicate or inconsistency in verbal communication with observed behaviors were barriers (II). Time and multidimensional communication approaches could bridge these barriers (I, II).

Study III and IV showed acceptable reliability for the mode, median and maximum measures. Rank correlations for individual 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, generally were lower than patients’ recall of pain.

The findings described beneficial effects of patient self-reported pain, however present healthcare did not fully support the utilization of pain scales. Because of the simple measurement characteristics, the use of daily NRS average pain measures, 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.

Place, publisher, year, edition, pages
Jönköping: Jönköping University, School of Health and Welfare, 2017. 84 p.
Series
Hälsohögskolans avhandlingsserie, ISSN 1654-3602 ; 081
Keyword
healthcare professionals, pain scales, postoperative pain assessment, collaboration, communication, routines, habits
National Category
Nursing
Identifiers
urn:nbn:se:hj:diva-35361 (URN)978-91-85835-80-5 (ISBN)
Public defence
2017-05-11, Forum Humanum, School of Health and Welfare, Jönköping, 13:00 (English)
Opponent
Supervisors
Available from: 2017-04-20 Created: 2017-04-12 Last updated: 2017-04-24Bibliographically approved

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