CHAPTER II

LITERATURE REVIEW

The literature review presents concepts and theories of pain, types of pain,

postoperative pain, pathophysiology of postoperative pain, impact of postoperative

pain, postoperative pain management, factors related to postoperative pain

management, and nurses’ role in pain management in Bhutan.

Concepts and Theories of pain

Pain is often described in the literature as a subjective complaint that acts as

a warning sign (Hartrick, 2004). Pain is “whatever the experiencing person says it is,

existing whenever he/ she says it does” (McCaffery & Pasero, 2002). This definition

emphasizes that pain is a subjective experience. It also stresses that the patient, not the

health care provider, has the authority on the pain, and that his or her self-report is the

most reliable indicator of pain. According Gate control theory, pain is not just a

physiological response to tissue damage but also includes behavioral and emotional

responses expected and accepted by one cultural group which may influence the

perception of pain (Melzack & Wall, 1965; Miaskowski, 2004). Some Psychologists

linked pain with suffering and suggested that certain psychological modulators of pain

sensitivity were dependent on the patient’s characteristics (Jones & Zachariae, 2004).

As a result of the changes in the conceptualization of pain, multidisciplinary

approaches to its treatment have been developed.

Many theories have been proposed to explain the mechanisms of pain

caused by the body tissue trauma or damage of peripheral nerves. In 1943 Livingston

cited in (Bonica, 2000) proposed the theory of central summation. He suggested that

stimulation resulting from nerve and tissue damage activates fibers that project to

neuron pools in the spinal cord, in consequence, creating activity that spreads to

lateral horn cells and ventral horn cells in the spinal cord, activating the sympathetic

nervous system, and somatic motor system. As a result, this activation produces

vasoconstriction of the blood vessels, increases work load of heart, and induces

muscular spasm, and fear and anxiety (Bonica, 2000).

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Hardy, Wolff, and Goodell (1952) introduced biopsychosocial theory of pain

that explained the influence of the psychological factors on pain. The theory

suggested the two components of pain: the perception of pain, and the reaction to

pain. The perception of pain is a process that has special structural, functional, and

perceptual properties, and is accomplished by means of simple and primitive neural

receptive and conductive mechanisms. The reaction to pain, conversely, is a complex

process relating the cognitive functions of past experience, culture, and a range of

psychological factors that influence the reaction to pain stimuli. In other words, this

theory is linking the stimulus intensity and the perception of pain.

In 1959, Noordenbos cited in Bonica (2000) proposed the sensory

interaction theory. This theory proposed that there are two systems involved in

transmission of pain: a slow system that involved the unmyelinated and thinly

myelinated fibers, and a fast system that involved the large myelinated fibers.

Noordenbos suggested that the slowly conducting somatic afferent fibers and small

visceral afferents project into the dorsal horn of the spinal cord and inputs from the

small fibers are transmitted to the brain to produce pain. The fast-acting fibers inhibit

transmission of impulses from the small fibers, and prevent summation from

occurring (Bonica, 2000).

The classic gate control theory of pain, described by Melzack and Wall

(1965) proposed to explain the relationship between pain and emotions. According to

this theory, a gating mechanism occurs when a pain impulse travels to the dorsal horn

of the spinal cord where trigger cells (T-cells) influence the transmission of pain

impulses. The pain stimulation of the large-diameter fibers inhibits the transmission of

pain, the gate closes, and impulses are less likely to be transmitted to the brain. On the

other hand, when smaller fibers are stimulated, the gate is opened. This mechanism is

influenced by descending nerve fibers from areas in the brain that regulate thought,

beliefs, and emotions. The gate-control theory helps to understand the role of

psychological factors in the perception of pain. The theory explains the effects of

some interventions such as distraction and imagery in relieving pain. All of the

proceeding theories have explained pain related to tissue damage that is mostly related

to acute pain such as the postoperative pain.

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Types of pain

Pain has been classified into two types, acute pain and chronic pain. Acute

pain is a complex, unpleasant experience with emotional, and cognitive, as well as

sensory, features that occur in response to tissue trauma. Acute pain resolves with

healing of the underlying injury (Americian Pain Society [APS], 2001). Acute pain is

usually nociceptive, but may be neuropathic. Common sources of acute pain include

trauma, surgery, labor, medical procedures, and acute disease states, and are usually

accompanied by physiological and behavioral responses of the patient (APS, 2001;

Vadivelu, Christian, Whitney, & Sinatra, 2009). Acute pain serves as an important

biological function, as it warns of the potential for or extent of injury. A host of

protective reflexes (e.g. withdrawal of a damaged limb, muscle spasm, autonomic

responses) often accompany it. Postoperative pain is an acute pain that lasts less than

three months (Mackintosh, 2005).

Chronic pain is recognized as pain that extends beyond the period of

healing, with levels of identified pathology that often is low and insufficient to

explain the presence or extent of the pain. Chronic pain is also defined as a persistent

pain that “disrupts sleep and normal living, ceases to serve a protective function, and

instead degrades health and functional capability. Chronic pain may be nociceptive,

neuropathic, or both and caused by injury (e.g. trauma, surgery), malignant

conditions, or a variety of chronic non-life threatening conditions (e.g. arthritis,

fibromyalgia, neuropathy). Chronic pain represent disease itself and last more than

three to six months (APS, 2001; Simpson, 2008; Vadivelu et al., 2009).

Postoperative pain

Definition and incidence of postoperative Pain

Postoperative pain is the normal, predicted physiological response to an

adverse chemical, thermal, or mechanical stimulus associated with surgery. It is

generally time-limited and is responsive to therapy (International Association for

Study of Pain [IASP], 1994; Mackintosh, 2007). Acute postoperative pain is defined

as a complex unpleasant experience with emotional and sensory features that occur in

response to trauma (IASP, 1994). Postoperative pain is a chemical, thermal or

16

mechanical stimulus resulting from tissue injury due to surgery (Coll, Ameen, &

Mead, 2003). Postoperative pain is an unpleasant symptom experienced by patient

due to trauma.

Unrelieved pain is a central health care problem (Dahl et al., 2003;

Dunwoody, Krenzischek, Pasero, Rathmell, & Polomano, 2008; Layzell, 2008;

Manias, 2003). Costantini, Viterbori, and Flego (2002) undertook a large-scale study

in Italy to determine the prevalence of pain among 4121 patients in 30 hospitals.

Findings concluded that over 56% of patients experienced pain in the 24 hours

postoperatively, with almost 30% being of severe intensity. It was verified that over

43% of participants experienced pain during the interview. Similarly, Salomon et al.

(2002) established that 55% of 998 patients in a large hospital in France had

experienced pain in the previous 24 hours.

More recently Strohbuecker, Mayer, Sabatowski, and Evers (2005)

interviewed 561 patients. It was reported that in the 24-hours postoperatively 63% of

these patients experienced pain with 58% indicating that their pain was moderate to

severe and 36% identifying the pain as severe in nature. Sawyer, Haslam, Robinson,

Daines, & Stilos (2008) established the prevalence of postoperative pain in 114

patients in a large Canadian teaching hospital. The incidence of pain in these patients

was 71% at the time in which the interview was carried out. In addition, almost 32%

of patients experienced moderate to severe pain at the time of interview. It was found

that in the 24 hours postoperative period, over 76% reported moderate to severe pain,

and 47.3% reported severe pain.

Pathophysiology of postoperative pain

Although a comprehensive overview of the nociceptive processing of acute

postoperative pain is beyond the scope, there have been several recent developments

in the study of the nociception of acute postoperative pain. Neurophysiologic and

pharmacological studies suggest that incisional pain differs in its mechanism from

other inflammatory or neuropathic pain. Hyperalgesia in the region of the incision is

thought to be mediated by sensitization of Aδ-fibre and C-fibre nociceptors and the

conversion of mechanically insensitive or silent Aδ nociceptors to mechanically

sensitive fibers after incision. Studies showed an important role of α-amino-3-

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hydroxy-5-methyl-4-isoxazole-propionate (AMPA)/ kainate ionotropic excitatory

amino acid receptors for incision-induced pain, hyperalgesia, and spinal sensitization.

Increased lactate concentrations and low pH occur in skin and muscle wounds after

incision and suggest that an ischemic pain mechanism might contribute to

postsurgical pain. Central neuronal sensitization probably contributes to postoperative

pain and hyperalgesia. Neurophysiological studies in animal models have shown an

increase in the prevalence and rate of spontaneous activity of spinal dorsal horn

neurons after skin and deep muscle incision. However, the precise role of central

sensitization in the development of persistent postoperative pain is uncertain (ASA,

2012; Wu & Raja, 2011).

Impact of postoperative pain

Unalleviated postoperative pain can result in both short and long term

negative consequences. These undesirable effects can cause detrimental outcomes for

patients in terms of mortality and morbidity. Unrelieved postoperative pain may result

in a variety of physiological reactions including: an increase in cardiac output, heart

rate, blood pressure, and oxygen consumption (Hutchison, 2007; Smeltzer & Bare,

2004; Spacek, 2006; Twycross, 2002). These physiological responses may predispose

the patient to the development of various disorders, including myocardial infarction,

myocardial ischemia, and left ventricular dysfunction (Smeltzer & Bare, 2004). In the

postoperative period unrelieved pain can cause a decrease in mobility. Immobilization

can subsequently result in complications such as the formation of thrombosis, the

development of respiratory problems including pneumonia, as well as the breakdown

of skin, particularly pressure areas, and constipation. Unrelieved pain can have

negative impact in terms or quality of life both physically, and psychologically

(Spacek, 2006; Twycross, 2007).

Furthermore it has been suggested that even momentary intervals of acute

pain in the postoperative period can induce lasting chronic pain. It has been noted in

the literature that unrelieved postoperative pain can predispose patients to delayed

recovery, and a prolonged hospital stay (Hunter, 2000; Roykulcharoen & Good 2004).

Additionally, unalleviated postoperative pain generates problems for society in terms

of increased costs and healthcare expenditure. Inadequate pain control has been

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described as being unethical, uneconomical, and clinically unsound (Hunter, 2000).

The consequences of inadequately treated postoperative pain responses can be broadly

classified as inflammation, hyperalgesia, hyperglycaemia, protein catabolism,

increased free fatty acid levels (lipolysis), and changes in water and electrolyte flux.

1. Acute postoperative hypertension

Acute postoperative hypertension (APH) is a common occurrence after

surgery that has important implications. APH has an early onset, being observed

within 2 hours after surgery, and is typically of short duration, with most patients

requiring treatment for 6 hours or less. Occasionally, APH may persist for 24 48

hours. Postoperative complications of APH may include hemorrhagic stroke, cerebral

ischemia, encephalopathy, myocardial ischemia, myocardial infarction, cardiac

arrhythmia, congestive heart failure with pulmonary edema, failure of vascular

anastomosis, and bleeding at the surgical site. For some complications, it is not clear

whether the blood pressure elevation precedes the development of the complication or

is a sequele of the complication (ASA, 2012; Mackintosh, 2007).

2. Hyperglycemia

Hyperglycemia is broadly proportional to the extent of the injury response.

Injury response mediators stimulate insulin-independent membrane glucose

transporters glut-1, 2 and 3, which are located diversely in brain, vascular

endothelium, liver and some blood cells. Circulating glucose enters the cells that do

not require insulin for uptake, resulting in cellular glucose overload and diverse toxic

effects. Excess intracellular glucose non-enzymatically glycosylates proteins such as

immunoglobulin, rendering them dysfunctional (Vanden-Berghe, 2004).

Alternatively, excess glucose enters glycolysis and oxidative phosphorylation

pathways, leading to excess superoxide molecules that bind to nitric oxide (NO), with

formation of peroxynitrate, ultimately resulting in mitochondrial dysfunction and

death of cells served by glut-1, 2 and 3 (Carli & Schricker, 2009). Even modest

increases in blood glucose can be associated with poor outcome particularly in

metabolically challenged patients such as people with diabetes. Fasting glucose levels

over 7mmol/L or random greater than 111mmol/L were associated with increased in

hospital mortality, a longer length of stay, and higher risk of infection in intensive

care patients (Vanden-Berghe, 2004).

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3. Lipotoxicity

Free fatty acid (FFA) levels are increased due to several factors associated

with the injury response, and its treatment and can have detrimental effects on cardiac

function. High levels of FFA can depress myocardial contractility (Korvald, Elvenes,

& Myrmel, 2000). Increase myocardial oxygen consumption (without increased work)

and impair calcium homeostasis and increase free radical production leading to

electrical instability and ventricular arrhythmias (Oliver & Opie, 1994).

4. Protein catabolism

The injury response is associated with an accelerated protein breakdown and

amino acid oxidation, in the face of insufficient increase in protein synthesis.

Following abdominal surgery, amino acid oxidation and release from muscle is

increased by 30% and 90% respectively, while whole body protein synthesis

increased only 10% (Harrison, Lewin, Halliday, & Clark, 1989). Fifty grams of

nitrogen may be lost (1 g nitrogen = 30 g lean tissue) which is equivalent to 1500 g of

lean tissue after cholecystectomy. Importantly, the length of time for return of normal

physical function after hospital discharge had been related to the total loss of lean

tissue during hospital stay (Chandra, 1983). Protein represents both structural and

functional body components, thus loss of lean tissue may lead to delayed wound

healing, reduced immune function and diminished muscle strength all of which may

contribute to prolonged recovery, and increased morbidity (Watters, Clancey,

Moulton, Briere, & Zhu, 1993). An overall reduced ability to carry out activities of

daily living (ADLs) results from muscle fatigue and muscle weakness. Impaired

nutritional intake, inflammatory metabolic responses, immobilization, and a

subjective feeling of fatigue may all contribute to muscle weakness. Such effects are

broadly proportional to the extent of injury but there are major variations across

populations, with durations also varying up to 3 to 4 weeks (Christensen, Nygaard,

Stage, & Kehletlet, 1990).

5. Injury-induced organ dysfunction

Pain from injury sites can activate sympathetic efferent nerves, and increase

heart rate, inotropy, and blood pressure. Sympathetic activation increases myocardial

oxygen demand, and reduces myocardial oxygen supply, the risk of cardiac ischemia,

particularly in patients with pre-existing cardiac disease is increased. Enhanced

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sympathetic activity can also reduce gastrointestinal (GI) motility. Severe pain after

upper abdominal, and thoracic surgery contributes to an inability to cough and a

reduction in functional residual capacity, resulting in atelectasis, and ventilation-

perfusion abnormalities, hypoxemia, and an increased incidence of pulmonary

complications. The injury response also contributes to a suppression of cellular, and

humoral immune function, and a hypercoagulable state following surgery, both of

which can contribute to postoperative complications. Patients at greatest risk of

adverse outcomes from unrelieved acute pain include very young or elderly patients,

those with concurrent medical illnesses, and those undergoing major surgery (Liu &

Wu, 2008).

In summary, acute postoperative pain leads to physical and psychological

consequences. It leads to complications, delay recovery from surgery, adding in the

increasing rate of morbidity, poor patient outcome, and frequent readmission to the

hospitals, and over all unwanted sufferings for the patients, and the family members.

Management of postoperative pain

Postoperative pain management is a comprehensive action of nurses in

relieving postoperative pain including assessment, intervention, evaluation, and

documentation. The goal of postoperative pain management is to reduce or eradicate

discomfort, prevent complications, facilitate the recovery process, and to attain a pain

free status whenever possible (APS, 2003; IASP, 1994).

1. Assessment

In order to accomplish adequate pain control, it is necessary to assess pain

on a regular schedule as well as following any new pain control intervention. In

general, pain should be assessed approximately 15-30 minutes after administering

parenteral medication, and 60 minutes after administering oral medication. During the

initial 24-hour postoperative period, pain should be assessed at least every 2 to 4

hours. If pain is well controlled, the pain intensity should be assessed routinely with

vital signs (IASP, 1994; Mackintosh, 2007; Vickers, 2007). Assessment of pain

involves asking the patient to describe the pain (quality, duration, onset), determine

pain location from the patient’s report, document intensity, quality and location,

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depending upon the condition of the patient, a comprehensive pain assessment

including description of behavior, and impact, assessing adverse effects associated

with inadequate or intolerable interventions (sedation, inadequate respiration, nausea,

vomiting, pruritis, numbness and weakness) is done.

Quantifying the intensity of pain is an essential part of initial, and ongoing

pain assessment; it is quantified by number of scales. Commonly used unidimensional

scales in assessment of pain include the Verbal Rating Scale (VRS), the Numeric

Rating Scale (NRS), a Visual Analog Scale (VAS), and a Pictorial Facial Scale. The

choice of pain scale may depend on the patient’s age, ability to communicate, and

other specific circumstances (ASA, 2012; Mackintosh, 2007).Without assessment it is

impossible to identify the nature of pain, the individual characteristics of pain or to

gauge the effectiveness of pain management interventions (Pain is subjective in

nature, the multidimensions of pain includes physiological, sensory, cognitive,

affective and socio-cultural dimensions (Hinshaw, Feethaw, & Shaver, 1999;

Giordano, Abramson, & Boswell, 2010).

1.1 Intensity evaluation of pain intensity or severity is always an important

aspect of any complete pain assessment and should be conducted in a manner

appropriate to the population. In other words, approaches for assessing pain intensity

should be valid, and reliable for the patient’s age, and other potential factors that may

impact successful, and accurate reporting of pain (e.g. sex, race, education, sensory

capability). Pain intensity is the least stimuli at which the person perceives a sensation

(Mackintosh, 2007; McCaffery & Pasero 1999).

1.2 Quality in the assessment of pain, information on pain quality is critical.

The quality of pain is determined by sensory, affective, and evaluative properties of

pain including constant, burning, pulsing, intermittent, shooting, and electric shock

like pain. It has been demonstrated clinically that patients with neuropathic pain are

significantly more likely to use six particular sensory adjectives (“electric-shock,”

“burning,” “tingling,” “cold,” “pricking,” and “itching”) to describe their pain

(Bressler, Hange, & Mcguire, 1986; Coll et al., 2003).

1.3 Location the location, and distribution of the pain is important clinical

information because most patients have two or more sites of pain. Neuropathic pain

often correlates with the degree of neural lesion. Most often pain is projected and,

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with few exceptions, the pain distribution matches the level of the lesion. The pain

that the patient may be referring to may be different than the one the nurse or

physician is talking about. Having the patient point to the painful area can be more

specific, and help to determine interventions (Mackintosh, 2007; McCaffery &

Pasero, 1999).

1.4 Duration The duration of the pain include whether its onset was sudden

or gradual, and whether the pain is intermittent, continuous, or paroxysmal.

Breakthrough pain refers to a transitory exacerbation or flare of pain occurring in an

individual who is on a regimen of analgesics for continuous pain. Patients need to be

asked, “Is your pain always there, or does it come and go?” or “Do you have both

chronic, and breakthrough pain?” (Mackintosh, 2007; McCaffery & Ferrell, 1997).

1.5 Aggravating/ alleviating factors asking the patient to describe the

factors that aggravate or alleviate the pain will help to plan interventions. A typical

question might be, “What makes the pain better or worse?”Analgesics, non-

pharmacologic approaches (massage, relaxation, music or visualization therapy,

biofeedback, heat or cold), and nerve blocks are some interventions that may relieve

the pain. Other factors (movement, physical therapy, activity, intravenous blood

draws, mental anguish, depression, sadness, bad news) may intensify the pain (ASA,

2012; Mackintosh, 2007; McCaffery & Pasero 1999).

There are many assessment tools found in the literature, and many scales

have been developed to assist nurses in determining the severity of pain. The use of

standardized scales has several advantages. Firstly, they are reliable and objective,

and thus the accurate way to rate pain severity (Ware, Epps, Herr, & Pachard, 2006).

Secondly, they take short time to implement. Thirdly, the same scales can be used to

assess the effectiveness of interventions (Coll et al., 2003). The commonly suggested

standardized tools are the Numeric Rating Scale (NRS), and the Visual Analogue

Scale [VAS] (Coll et al., 2003; Mackintosh, 2007). When using the NRS, the patient

is asked to rate his pain intensity on a scale of 0 (no pain) to 10 (the worst possible

pain). The VAS is a horizontal line, 100 mm in length, anchored by word descriptors

at each end. The patient marks on the line the point that represents his current state.

The VAS score is determined by measuring in millimeters from the left hand end to

the patient’s marks (Coll et al., 2003; Mackintosh, 2007).

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Several studies had been undertaken with a view to ascertain how nurses

assess postoperative pain. Manias, Bucknall, and Botti (2004) conducted an

observational study with 52 nurses caring for patients in the postoperative period.

A total of 316 cases were observed which involved nurses in the process of

assessment, and management of postoperative pain. It was established that 43.7% of

the times no pain assessment was carried out by nurses. The incorporation of a pain

assessment tool occurred in less than 9% of the cases. Furthermore, when patients

expressed difficulty in comprehending the tool, there was little attempt made by

nurses to clarify the meaning. In order for patients to effectively rate their pain, it is

essential that they fully comprehend the pain assessment tool.

Similarly, the study of Idvall and Berg (2008) described how 221 orthopedic

patients assessed their quality of care by utilizing the questionnaire ‘Strategic and

Clinical Quality Indicators in Postoperative Pain Management’. It was illustrated that

the regular use of pain assessment tools received a low score where only 21% of the

sample of patients totally agreed that a pain assessment tool was used on several

occasions each day.

Sloman, Rosen, Rom, & Shir (2005) used descriptive comparative design to

compare patients’ self-ratings of pain with nurses’ ratings of the patients’ pain in

Israel. Questionnaire for pain sensation, pain affect, and present pain intensity (PPI) at

rest and on movement; (b) visual analogue scales for overall pain intensity, suffering,

and satisfaction with treatment were used. The result of the study showed that nurses

significantly underestimated all dimensions of pain on the above scales, (t =3.131, p =

.002), pain affect (t = 4.410, p < .001), PPI at rest (t = 3. 498, p < .001), PPI on

movement (t = 6.278, p < .001), overall pain intensity (t = 2.235, p = .002), and

patient suffering due to pain (t =3.774, p < .001).

Furthermore, pain necessarily may not be associated with a change in

physical signs. In the study of Gillies, Smith, and Parry (1999) out of 351 patients

surveyed, almost half of these participants believed that the nurses did not know when

they were in pain. Despite this revelation from the patients, the healthcare

professionals in this study believed that their pain assessments were always (100%),

usually (70%), or sometimes (27%) accurate.

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2. Pain interventions

The principal goal of postoperative pain management is to reduce or

eradicate discomfort, prevent complications, facilitate the recovery process and to

attain a pain free status whenever possible (IASP, 1997). Traditionally, pain

management interventions were focused predominantly on the use of pharmacological

therapies alone. However, more recently it has been acknowledged that the inclusion

of non-pharmacological therapies integrated into the provision of postoperative care

plays an important role in enhancing, and augmenting the relief of postoperative pain.

Subsequently, a multidimensional approach in the alleviation of postoperative pain is

a prerequisite to achieving optimum pain relief. The choice of pain therapy is

determined by the location, severity and character of pain (Spacek, 2006; Smeltzer &

Bare 2004).

2.1 Pharmacological interventions

Pharmacological interventions are primary in the management of acute

postoperative pain. Opioid analgesics are the cornerstone of pharmacological

interventions for postoperative pain management (World Health Organization

[WHO], 1998). Usually three types medications are used to alleviate patient’s

postoperative pain including opioids analgesics, non-opioids analgesics, and adjuvants

(Mackintosh, 2007; WHO, 1998).

2.1.1 Opioid analgesics

Opioids are fundamentally the most potent, and effective analgesics

prescribed in postoperative pain thus they are the foundation of pharmacological

management of acute postoperative pain (WHO, 1998). Opioids are the derivatives of

opium that can modulate the perception of pain by binding to mu, kappa, or delta

receptors in the periphery, dorsal horn, and central nervous system (Kanner, 2003;

Barber, 1997). Opioid analgesics consist of natural agents including morphine,

codeine, and synthetic agents such as fentanyl. Currently there are two types of

opiods analgesics, the opiods agonists include codeine, methadone, hydromorphine,

meperidine, morphine, and fentanyl, the opioids agonist-antagonist includes

burenorphine, nalbuphine, butorphanol, and pentazocine. The common route of

opioids administration includes oral, parenteral, and intrathecal.

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However, analgesics have many side effects including respiratory

depression, addiction, sedation, constipation, puritus, nausea and vomiting (Barber,

1997; Mackintosh, 2007). Tolerance, physical dependence, and psychological

dependence are not considered to be the adverse effects of opioids, however these are

the key concepts nurses should understand. Misconceptions of these terms lead to

inadequate pain treatment. Tolerance is a phenomenon in which a patient is less

susceptible to the effect of drug as a consequence of its prior administration. There

are three types of tolerance, acute, chronic, and cross tolerance. Acute tolerance is a

term used to describe tolerance that develops very rapidly following either a single

dose or a few doses given over a period of time. Chronic tolerance is described for the

observation that a drug administration over a longer period of time produces reduced

drug effects. Cross tolerance is used when tolerance to one drug confers tolerance to

another (Dafters & Odber, 1989).

Physical dependence is the term used to describe the phenomenon of

withdrawal when opioid is abruptly discontinued or an opioid antagonist is

administered. Both tolerance, and physical dependence are predictable

pharmacological effects seen in response to repeated administration of opioids.

Psychological dependence or addiction is described as a pattern of drug use

characterized by a continued carving for an opiod, manifested as compulsive, drug

seeking behavior, and overwhelming involvement in drug use (WHO, 1998).

Misconception about incidence of opioid addiction is high, is well documented in

pain literature (McCaffery & Ferrel, 1996).

2.1.2 Non-opioid analgesics

Other analgesic preparations are also considered and utilized in the

management of postoperative pain. Alternative non-opioid analgesics such as non-

steriodal anti-inflammatory drugs (NSAIDs), and acetaminophen (paracetamol) are

being regularly utilized. NSAIDs play a pivotal role in postoperative pain

management when used in combination with opioids. NSAIDs are a group of

chemical agents with a spectrum of analgesic, antiinflammatory and antipyretic

effects (Krenzischek, Dunwoody, Polomano, & Rathmell, 2008). It has been

demonstrated that NSAIDs improve analgesia by producing a synergistic analgesic

effect, and decrease opioid dosage (Spacek, 2006). Consequently, this opioid sparing

26

effect can essentially decrease opioid-related adverse effects such as respiratory

depression. Acetaminophen (paracetamol) is an effective analgesic available in both

oral and intravenous preparations. The exact mechanism of action remains unclear but

it is advantageous for the reason it is well tolerated with minimal contra-indications

(Macintyre & Schug, 2007; Vickers, 2007).

2.1.3 Adjuvant analgesics

These medications are used in combination with opioids and non-

opioids to manage pain. These agents include anticonvulsants, antidepressants,

corticosteroids, adrenergics agonist, and local anesthetics (Mackintosh, 2007).

2.2 Non-pharmacological interventions

It is considered that these therapies help the standard pharmacological

treatment in pain management. While medical drugs are being used for treating the

somatic (physiological) dimension of the pain non-pharmacological therapies aim to

treat the affective, cognitive, behavioral, and socio-cultural dimensions of the pain. In

general they are stated as physical, cognitive, behavioral, and other complementary

methods or as invasive or non-invasive methods. Meditation, progressive relaxation,

dreaming, rhythmic respiration, therapeutic touch, transcutaneous electrical nerve

stimulation (TENS), hypnosis, musical therapy, acupuncture, and cold and hot

treatments are non-invasive methods (Taylor & Stanbury, 2009; Mackintosh, 2005).

2.2.1 Massage

Massage is defined as the systematic manipulation of soft tissues by

manual or mechanical means. Nurses have used massage such as a back rub to

improve circulation, promote comfort, and enhance sleep. More recently investigators

had examined hand, and foot massage as an alternative to back or body massage. The

duration of massage varies from 5 to 20 minutes (Wells et al., 2005).

Mitchinson et al. (2007) conducted a randomized controlled trial with 605

patients undergoing major surgery to test whether massage therapy relieves

postoperative pain, and anxiety among patients who experience unrelieved

postoperative pain. Patients were assigned to the following 3 groups: (1) control

(routine care), (2) individualized attention from a massage therapist (20 minutes), and

(3) back massage by a massage therapist each evening for up to 5 postoperative days.

The findings revealed that compared to the control group, patients in the massage

27

group experienced short-term (preintervention vs postintervention) decreases in pain

intensity (p = .001), pain unpleasantness (p = .001), and anxiety (p = .007). In

addition, patients in the massage group experienced a faster rate of decrease in pain

intensity (p = .002) and unpleasantness (p = .001) during the first 4 postoperative days

compared with the control group. There were no differences in the rates of decrease in

long-term anxiety, length of stay, opiate use, or complications across the 3 groups.

2.2.2 Cognitive strategies

Distraction technique changes patient’s sense of control as well as

increases pain tolerance, and decreases pain intensity. This technique helps to reduce

mild to moderate pain during certain procedures including change of dressing,

intramuscular injection, and vein puncture. Distractions techniques include rhythmic

breathing, listening to music, laughing, counting, watching television, reading,

exercising, resting, talking on phone, and visiting places and people (Mackintosh,

2007, Wells et al., 2005).

Music as a non-pharmacological treatment for pain was tested by Roy,

Peretz, & Rainville, (2008) and Zhao and Chen (2009). Both studies evaluated effects

of musical interventions upon pain perception and both studies reported that pleasant

or cheerful music decreased perceptions of pain induced by heat while unpleasant or

sad music increased perceptions of pain under the same conditions. Zalewsky, Vinker,

Fiada, Livon, & Kitai, (1998) surveyed 118 patients whose surgery was performed

while music played in the surgical suite, 95% of participants did not feel disturbed by

the background music, 89% reported feeling more positive about their surgery, and

80% thought that the music supported the doctor’s performance and, therefore, led to

a better patient-doctor interaction.

2.2.3 Relaxation

There are many methods available to achieve a relaxation. Some

require initial training, and practice to be used effectively; progressive muscle

relaxation, systematic relaxation, and autogenic training skills that require some

practice. Each session using progressive, systematic, or autogenic training may take

15–30 minutes. Typically in research, the instructions are delivered via audiotape, a

method that may be used for hospitalized patients as well. Simpler forms of

relaxation, which may be more suitable to institute during an acute pain episode,

28

include rhythmic breathing (Good, Anderson, Ahn, Cong, & Stanton-Hicks, 2005;

Roykulcharoen, & Good, 2005; Wells et al., 2005).

He at al. (2010) conducted a quasi-experimental pre and post-test design

with a convenience sample of 108 registered nurses in two public hospitals in

Singapore. The results revealed that there was a statistically significant increase in

nurses’ use of five non-pharmacological methods for children’s postoperative pain

relief between pre- and post-test. These were: imagery (p = .001), positive

reinforcement (p = .004), thermal regulation (p = .003), massage (p < .001) and

positioning (p = .046).

Furthermore, He et al. (2011) conducted a survey with a convenience sample

of 151 registered nurses (RNs) in Singapore, to examine nurses’ use of non-

pharmacological methods for school-age children’s postoperative pain relief. The

result revealed that nurses who were younger, had less education, lower designation,

less working experience, and no children of their own used non-pharmacological

methods less frequently. Non-pharmacological methods used were relaxation,

breathing technique, distraction, positive reinforcement, preparatory information,

imagery, positioning, thermal regulation, massage, emotional support, comforting/

reassurance, touch, presence, helping with activities of daily living, and creating a

comfortable environment.

Similarly Kwekkeboom, Bumpus, Wanta, and Serlin (2008) conducted a

study with sample of 724 oncology staff nurses to examine the nurses’ use of four

nondrug interventions (music, guided imagery, relaxation, distraction) and to identify

factors that influence their use in practice. The results indicated that the percentages

of nurses who reported administering the strategies in practice at least sometimes

were 54% for music, 40% for guided imagery, 82% for relaxation, and 80% for

distraction. Use of each non-drug intervention was predicted by a composite score on

beliefs about effectiveness of the intervention (e.g. perceived benefit; p = .025) and a

composite score on beliefs about support for carrying out the intervention (e.g. time; p

= .025). In addition, use of guided imagery was predicted by a composite score on

beliefs about characteristics of patients who may benefit from the intervention (e.g.

cognitive ability; p = .005).

29

3. Evaluation

Ongoing assessment is necessary to evaluate changes in pain and the

effectiveness of management. The American Pain Society stresses that heath care

professionals should consider pain as the fifth vital sign (Campbell, 1995; Merboth &

Barnason, 2000). Therefore, the patient’s pain should be assessed at least as often as

vital signs are taken or whenever necessary to monitor effectiveness, and side effects

of the intervention. Accuracy in pain assessment is a major factor in measuring the

adequacy of pain management. This implies that health care professionals should

identify the presence of postoperative pain for each patient, and score its intensity

using standardized scales (APS, 2003; JCAHO, 2002). Pain scores are documented in

writing, making them readily available to all the health care professionals.

4. Documentation

Documentation of patient care is an integral, and necessary duty required of

nurses which underscores professional autonomy. Additionally, the documentation of

care structures the domain of nursing in a way that is identifiable (Heartfield, 1996).

Nursing records are purposeful in ensuring, and sustaining consistency and continuity

of care (Griffith, 2004). Although documentation is not direct patient care it is

extremely beneficial as it enables to monitor the progress of the patients. Evaluation

of care is a particularly important nursing duty as it determines the patient’s ongoing

needs, any progress made, the effectiveness of interventions, and it provides a means

for nurses to make decisions about care. Documentation is the central way in which

care is evaluated, and this underpins the significance of comprehensive nursing notes

to ensure appropriate evaluation of care. Subsequently, regardless of how good the

care provided to patients, if there is no documentation, substantiation and evaluation

of high quality clinical practice cannot be verified (Chanvej et al., 2004).

Abdalrahim, Majali, and Bergbom (2008) conducted a retrospective

approach to collect data on nurses’ documentation of pain assessment and

management in the first 72 hours postoperatively in surgical wards. A total of 322

records at six hospitals in Jordan were audited using three audit instruments; Pain and

Anxiety Audit Tool, the North American Nursing Diagnosis Association (NANDA)

form for characteristics of acute pain, and comprehensiveness assessment tool. The

results showed that there was no evidence of pain assessment documentation on the

30

first day of surgery in 113 (35%) of patient’s records. Pain location was the most

recorded information for pain assessment in 197 (61%) notes, and only14 (4.3%)

nurses used a pain scale. More than 53% of the records lacked information about

medication for pain management. There was a significant difference (p < .05) in all

the categories of pain documentation between the first day, and the subsequent days.

Nurses documented patients’ self-report of pain [297 (92.3%)], and patients’ crying

[200 (62.1%)]. More than 80% (273) of the records were ranked below the minimum

score for a satisfactory documentation. Chanvej et al. (2004) audited 425 patients’

records to evaluate the quality of postoperative pain documentation in the first 72

hours postoperatively. The study revealed that documentation of pain both before and

after giving analgesics were scarce, pain assessment items were documented

inconsistently, and below accepted standards. Similarly Stomberg, Lorentzen,

Joelsson, Lindquist, and Haljamae (2003) studied 2890 registered cases in the

database, a homogeneous 2-years sample of documentation charts. They found that

only 58% of the data charts were properly completed and entered into the database.

The database documentation routines were not found to function optimally.

Manias (2003) conducted a study in which nurses’ notes in 100 patients’

records of the postoperative period were audited. The study showed that nurses

documented inadequately in four major areas: pain assessment, use of

pharmacological intervention, use of non-pharmacological interventions, and outcome

of interventions.

Theory of Reasoned Action

The Theory of reasoned action of Ajzen and Fishbein (1980), assumes that

most actions of social relevance are under volitional control. Thus an individual’s

intention to perform or not perform an action is the immediate determinant of that

behavior. Usually there is a strong correlation between the intention to act and the

action. Barring unforeseen circumstances, where an action is under volitional control,

a person will act in accordance with the intention. Behavioral intentions are function

of personal, and interpersonal factors: a personal belief and the perceived beliefs of

significant others. When individuals believe that a behavior will result in valued

31

consequences, and they believe that important referents consider the behavior to be

worthwhile, they are likely to execute that behavior. Ajzen recognized that difficulties

are encountered when behavior is not favored by not having the necessary

opportunities or resources to act, i.e. the behavior is not volitional.

According to Ajzen and Fishbein (1980) Knowledge is the information and

skills acquired through education or experience regarding any behavior. Knowledge is

the base for development of nursing actions, such as those required for postoperative

pain management. For example, for patients experiencing pain, nurses should have

knowledge about patients’ expression of pain, pain physiology, drug actions, as well

as sources, and effects of pain. Nurses need this knowledge to perform nursing actions

to relieve patients’ pain (Ajzen & Fishbein, 1980).

According to Ajzen and Fishbein (1980) attitude is an individual’s positive

or negative feeling towards an object or feelings associated with performing a specific

action. A person’s attitude towards an object is based on his salient beliefs about that

object. An individual’s attitude towards pain management, for example, is a function

of his belief about pain management. If those beliefs associate the object or issue with

favorable attributes his attitude would tend to be positive. Conversely, a negative

attitude would result if the person associates pain management with unfavorable

attributes. It could be said that a person’s attitude toward some object or issue is

determined by his or her beliefs and that attitudes are measured by assessing the

beliefs of the person. The nurse would hold a favorable attitude towards a given

action (administering pain medication) if he or she believed that the performance of

the action would lead to mostly positive outcomes; on the other hand, if the nurse

believed that negative outcomes would result from the action, then he or she would

hold a negative attitude towards it (Ajzen &Fishbein, 1980).

Ajzen and Fishbein (1980) describes self-efficacy as a control factor,

reflecting the individual’s perceived control over the behavior, and beliefs about

the ease or difficulty of performing the behavior. This incorporates the individual’s

perception of the presence or absence of the necessary resources and opportunities to

perform the behavior.

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Factors Related to Postoperative Pain Management

According to the Agency for Healthcare Research and Quality (2002), there

are three factors related pain management including healthcare system related factors,

patients related factors, and healthcare professionals related factors. However, in this

study healthcare professional (nurses) related factors including knowledge, attitude,

and self-efficacy regarding postoperative pain management were examined. It is

evident from the literature that nurses scoring high in knowledge of pain management

have positive attitude and high self efficacy in pain management (Ampomah, 2009;

Chiang et al., 2006; Glajchen & Bookbinder, 2001). Therefore, this review focused in

knowledge, attitude, and self efficacy of nurses regarding postoperative pain

management since nurses are the health professional who care the postoperative

patient all round the clock.

1. Knowledge of postoperative pain management

Knowledge of postoperative pain management is nurses’ theoretical and

practical understanding of postoperative pain, and its management including

knowledge of assessment, intervention, evaluation, and documentation. The Theory of

Reasoned Action (Ajzen & Fishbein, 1980) states that knowledge is the information

and skills acquired through education or experience regarding any behavior. It

assumes that individuals having good knowledge of given behavior are more likely to

perform the behavior. Therefore, in order to be competent in the provision of high-

quality pain management, nurses must be knowledgeable in all facets of pain

management and the evidence-based strategies underpinning these practices.

Adequate pain management is reliant on the knowledge, attitudes, and subsequent

skills of healthcare professionals (Lewthwaite et al., 2011).

Numerous studies had been conducted to evaluate nurses’ knowledge of pain

management. A descriptive correlation study was used by Basak (2010) in

Bangladesh to examine the level of knowledge and attitudes, and nurses’ practices

regarding post-operative pain management with a sample of 100 nurses. He found

nurses had low level of knowledge and negative attitude, presented by the total mean

score of 59.05% (S.D = 5.62) with a minimum and maximum scores of 40% and 70%.

Nurses’ practice regarding postoperative pain management was in moderate level

presented by mean score of 77.81%, (S.D = 10.94) (Basak, 2010).

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A descriptive study was used by Al-Shaer et al. (2011) with a sample of 129

registered nurses (RN). They found the average knowledge score was 25.9 (S.D =

2.5). Scores ranged from a minimum of 20 to a maximum of 31. The majority of

respondents (n = 79, 61.2%) received a letter grade of B (80%-89%) or higher. No

statistical differences existed in knowledge scores with respect to shift worked, work

status, age category, and total years of nursing practice. Nurse having worked 16 or

more years on their particular nursing unit scored significantly higher than nurses who

having worked 1-5 years on their unit (Mean = 27.2; S.D = 2.3 vs. Mean = 25.0; S.D

= 2.5; p < .001).Total knowledge scores did not differ significantly by degree

preparation of the nurse. Baccalaureate prepared nurses (Mean = 26.4; S.D = 2.6),

and diploma prepared nurses (Mean = 26.0; S.D = 1.7) scored higher than nurses who

held an associate’s degree (Mean =25.7; S.D = 2.5). Baccalaureate prepared nurses

scored significantly higher on the 16 assessment items compared to nurses with other

preparation (p = .003).The authors concluded that although the results of this study

indicated relatively high knowledge scores, some nurses were not prepared adequately

to care for patients who experience pain. Knowledge of pain management principles,

and interventions was insufficient. Nurses continue to demonstrate inadequate

knowledge of pain assessment, and pain management interventions (Al-Shaer et al.,

2011).

Similarly, Abdalrahim, Majali, Stomberg, and Bergbomet (2011) explored

nurses’ knowledge, and attitudes towards pain in surgical wards in Jordan. The

sample consisted of sixty five registered nurses, and questionnaire (NKAS) comprised

of 21items were designed to test nurses’ knowledge of pain and their attitudes toward

its management. The finding revealed the overall percentage of correct answers of the

65 nurses was 45.7%, corresponding to an average number of correct answers of 9.2

of the 21 questions. The author concluded that participants had inadequate knowledge

of postoperative pain management (Abdalrahim et al., 2011).

A descriptive correlational study was used by Ampomah (2009) to compare

the knowledge, attitudes, and beliefs about pain management of West African-born

nurses working in the United States with their United States-born counterparts

including 187 nurses. Thirty seven item Nurses Knowledge and Attitude Survey

Regarding Pain (NKASRP) originally designed by Betty Ferrell and McCaffery in

34

1987, and revised in 2005 was modified into a 30 items questionnaire to assess the

knowledge of nurses regarding pain management. The study found insufficient

knowledge of pain management between West African born and United Sates born

nurses [50.7% West African vs. 60.1% United States] (Ampomah, 2009).

A descriptive cross-sectional study design was used by Lui, So, and Fong

(2008) to explore the knowledge, and attitudes regarding pain management among

nursing staff working in medical units in Hong Kong with a convenience sample of

143 nurses. Among the 25 items about pain management being assessed, the

percentage of correct scores on NKASRP was 47.72%, with a range of 20-76. The 10

items most frequently answered incorrectly indicated that the participants were weak

in pharmacological and non-pharmacological interventions for patients experiencing

pain. 71.3% of the participants believed that the most accurate judge of the intensity

of pain was the patient, only 1.4% believed that no patients over reported the amount

of pain. Discrepancy between participants’ attitudes, and practice was further

supported by the two scenarios used in NKASRP; even when two patients reported

the same level of pain, the participants believed that the one expressing discomfort to

be suffering a higher level of pain than the one with a relaxed manner. In addition,

71.1% of the participants believed that the patient should have to endure as little pain

as possible and should have prompt treatment. However, 64.3% would advise patients

to use non-drug techniques alone rather than concurrently with pain-relieving

medications. Findings of the study revealed that the participants had inadequate

knowledge of, and misconceptions about pain relief interventions (Lui et al., 2008).

2. Attitude towards postoperative pain management

An adequate postoperative pain management is reliant on the knowledge of

nurses. In addition to the knowledge of postoperative pain management, nurses

attitude of postoperative pain management significantly contributed to effective

postoperative pain management. Attitude towards postoperative pain management is

nurses’ positive or negative feeling towards postoperative management including pain

assessment, intervention, evaluation, and documentation. The TRA states an

individual will have positive attitude if he/she believes that the performance of the

behavior will lead to mostly positive outcomes, on the other hand, if the individual

believes that negative outcomes will result from the behavior, then he or she will hold

35

a negative attitude towards it. Therefore, if a nurse believes that her action leads to

positive outcomes such as comfort, and satisfaction to the patient, then she would

have a positive attitude towards postoperative pain management.

The literature recognized that, due to the subjective nature of pain, nurses’

attitude contribute to under treatment of pain. This can happen when clinicians make

pain management decisions for patients based on their own beliefs, and do not accept

patients’ self reporting as the ‘gold standard’ (Nash et al., 1993, Pasero & McCaffery,

2001). Nash et al. (1993) used focus based interviews with 19 participants to ascertain

that nurses’ attitudes affected pain management, and their administration of analgesia

particularly opiates. Their study revealed a range of erroneous beliefs, for example

that smaller patients need less analgesia, and terminally ill patients should have more

analgesia. Similarly, Richards and Hubert (2007) sought to understand the experience

of nurses with regard to pain relief, and concluded that expert nurses preferred to view

the patient holistically, listening to what the patient had to say and looking for other

pain cues before deciding what pain relief was suitable. The participants in this

qualitative pilot study stated that they found it difficult to put their own judgments

aside and accept what the patient said. These nurses further admitted to struggling

with their individual biases relating to pain and pain management.

Likewise a recent study of Phuong (2012), with a sample of 124 surgical

nurses found that the mean score of nurses’ attitudes toward postoperative pain

management was 69.35 (S.D = 5.26), the independent subscale such as scheduling

analgesic mean score was 12.09 (S.D = 1.39), the mean score of pain assessment was

21.49 (S.D = 1.91), the mean score for misconception for pain management, the use of

opioids was 27.65 (S.D = 2.99), and the mean score of non-pharmacological

management subscale was 8.12 (S.D = 1.13). McMillan, Tittle, Hagan, Laughlin, &

Tabler (2000) cited in Phuong (2012) found a variety of nursing attitudes that

interfere with the appropriate management of postoperative pain, nurses feel that

patients should experience pain as it a normal physiological functioning, they had a

fear that patient will be addicted to pain medication, and land up in respiratory

depression.

On the other hand Layman, Horton, and Davidhizar (2006) used a

convenience sample of 52 nurses in Midwest community hospital in the USA using

36

open ended questionnaires, with an aim to determine nurses’ attitude towards pain

management and found that attitude scores ranged from 6 to 28 with an overall mean

score of 8.3 indicating a positive attitude towards pain management. Positive beliefs

about pain assessment tools included the fact that ‘They help patients to be as

comfortable as possible’ and were ‘very beneficial to the patient’s well-being’. Others

stated, ‘Tools were an important part of assessing the pain properly and addressing the

problem effectively’. Some believed that ‘they are the best in resolving the problems

of pain’. These comments seemed to indicate that the use of the pain tool assisted

them in determining patients’ overall welfare, comfort, and assessing pain efficiently.

Other positive beliefs related to the value of pain assessment tools included providing

objective and measurable data. In fact, 22 responses supported this view and the belief

that the tools provided ‘accountability’ and helped to collect data. The use of the pain

tools gave nurses positive attitudes and beliefs that they could perform pain

assessment in a reliable, and dependable way through accurate documentation of pain

(Layman et al., 2006).

In addition, Boegeskov, Svantesson, and Bergbom (1994) used a qualitative

study with a sample of eight nurses from a Danish post anesthetic care unit. Most

nurses believed that patients should expect some level of postoperative pain, and that

short-lived pain is acceptable. Most expressed fear over the use of opioids,

particularly related to side-effects and the possibility of addiction (Boegeskov et al.,

1994).

Similarly, a qualitative study was undertaken in Australia by Helmrich et al.

(2001) to investigate nurses’ attitudes, and use of non-pharmacological therapies for

pain relief. It was establish that the majority of nurses (89.2%) stated they integrate

non-pharmacological therapies to assist in the management of patients’ pain.

Conversely, inspection of patient records in various studies identified that the

documentation of non-pharmacological approaches to pain management was minimal

to non-existent. However, it was unknown whether nurses utilized any non-

pharmacological approaches in these studies or simply excluded to document those

(Helmrich et al., 2001).

According to Power (2005) non-pharmacological therapies were seldom

utilized for acute postoperative pain relief. Several barriers hindering the

37

implementation of non-pharmacological interventions by nurses for the relief of pain

had been cited in the literature which includes: a lack of resources, time constraints,

lack of knowledge regarding non-pharmacological approaches to pain relief and lack

of professional support.

3. Self-efficacy in postoperative pain management

With increase in knowledge of postoperative pain management, attitude of

nurses change from negative to positive, subsequently, it affect the self-efficacy of

nurses in postoperative pain management. The TRA states that individual with high

internal control factor (self-efficacy) tend to perform behavior with ease and

confident. Therefore, in this study it was assumed that nurses with high self-efficacy

would manage postoperative confidently. A study of Chiang et al. (2006) examined

self-efficacy of 181 nurses in Taiwan after an educational program. Data were

collected by an extensive questionnaire that assessed nurses’ knowledge, attitudes,

and self-efficacy pain assessment and pharmacological and non-pharmacological pain

management. Before the pain education, the standard score for self-efficacy was

73.37, indicating that nurses were fairly confident at assessing and managing

children’s pain. The total standard score of self-efficacy at post-test was 87.7,

indicating that nurses’ self-efficacy in managing pain significantly (p < .001)

increased after the pain education program (Chiang et al., 2006).

Similarly, in a statewide cross-sectional survey conducted in Australia by

Edwards et al. (2001) to determine registered nurses' attitudes, subjective norms, and

perceived control, and self-efficacy to administer opioids to patients with pain. Four

hundred and forty six nurses participated in the study including the primary area of

clinical experience was surgical/ perioperative (29.4%), medical (19.5%), critical

care/ accident and emergency (13%), midwifery (11.9%), mental health (6.7%),

oncology (5.6%), gerontology (4.9%), pediatrics (3.6%), and general nursing (5.4%).

A self-report instrument, the Pain Management Survey was used. Results indicated

that respondents' attitudes towards opioids, and their administration to patients with

pain were generally positive. However, responses to particular items highlighted the

presence of negative attitudes that could have a major influence on nurses' pain

management. Nearly 40% of respondents did not agree that, in general, children and

patients with a history of opioid addiction should be given opioids for pain relief.

38

Over 20% agreed or were unsure whether patients who ordered analgesics every 4

hours and reported pain within those 4 hours should have to wait until their pain

relieving medication was due. One-third (32.8%) of respondents considered opioids

should not be required for longer than 3 days post-operatively and nearly 20% were

unsure about this. Nearly half (47.8%) felt that, in general, patients should be

encouraged to have non-opioids rather than opioids for pain relief. Just over one-third

(36%) agreed it was best to administer the least possible amount of opioids (Edwards

et al., 2001).

Nurses’ role in postoperative pain management in JDWNRH

Thimphu, Bhutan

Postoperative pain management is an important nursing responsibility.

Nurses in Bhutan play vital role in management of postoperative pain. There are three

categories of nurses in Bhutan including general nurse midwife (GNM) with diploma

in nursing education, bachelor degree nurses, and master degree nurses in JDWNRH.

However, the roles and responsibilities of all three categories of nurses are same

pertaining to postoperative pain management.

Although nurses receive very little knowledge of pain management during

the initial nursing training, they gain substantial knowledge from inservice taining,

short course training, from role model, feed back from evaluation, and on job training.

To ensure that nurses are capable of doing postoperative pain management activities,

they are kept on rotation for period of three to four months in different wards involved

in the care of postoperative patients. The senior nurses supervise the junior nurses in

daily nursing activities for a period of one year. During this period the senior nurses

teaches, guide, support, encourage, and help the novice nurses to gain knowledge, and

learn good nursing practices.

The head nurses of all the wards go for evening nursing rounds, and guide

the novice nurses in the performance of the postoperative pain management. Every

month, the head nurse meets with the medical director, and the nursing superintendent

to present the progress of the respective wards. Further the head nurses organizes

39

meeting with other nurses to share the views and plans to improve the management of

postoperative pain management.

Knowledge gained through practice, from role models, inservice trainings,

short course, and the physicians help nurses in the management postoperative pain.

The following pain management standard is followed in JDWNRH Thimphu, Bhutan.

The nurses assess the postoperative pain by physiological monitoring including

measurement blood pressure, and pulse. Administer the prescribed pain medications,

along with the non-pharmacological interventions depending upon the individual

judgment of the nurses. The evaluation of pain, the effects, and side effects of the

medications are done routinely. Further the physicians should be notified if the pain is

not relieved. The non-pharmacological methods includes, provision of a suitable

calm environment for the patient, eliminating sources of discomfort, such as full

bladder, infiltration of IV etc. Reposition the patient regularly to eliminate pressure

sores. Encouraging patient to move extremities while in the bed because activity

decreases muscle spasm and booster circulation. Teach the patients comfort measures

including relaxation, deep breathing exercises, listening to music, reading, watching

television, moving or coughing to prevent complications. However, opioid

administration had been identified as the area for greatest decision making and

potential conflict in nurses’ pain management this may be the lead nurses to develop

negative attitude towards managing pain adequately. Systemic opioid analgesics,and

NSAIDs are mostly prescribed as a variable dose and given by nurses on a PRN basis.

Thus, the nurses make the decisions concerning medication for pain relief.

Summary

Several studies were conducted around the world to evaluate nurse’s

knowledge of pain management, attitudes towards pain management, where there are

different cultures, different level of education, advanced technology, and well

developed nursing services. It was evident from literature, despite of advanced

technology in pain management nurses have inadequate knowledge of pain

management, negative attitude, and low self-efficacy in pain management. However,

the context of Bhutan is different, nursing service is developing, very little technology

40

and little research, and different culture, therefore this study is deemed necessary to

be conducted. In conclusion, pain is a subjective, and very personal experience

associated with actual or potential tissue damage. It is unpleasant emotional and

sensory experience. Despite of well developed technology, and advancement in pain

management, studies showed that postoperative pain is inadequately assessed and

managed by nurses. Unrelieved postoperative pain has many deleterious effects to the

body, and patients have to suffer unnecessarily. Therefore it is crucial responsibility

of the nurses to assess, and manage postoperative pain adequately, for this action

nurses need to have a good knowledge of pain management, positive attitude, and

confidence in the planning, and intervening the modalities of pain management.