1. The effectiveness of nurses in managing
postoperative pain in adult patients undergoing
general surgery
Rhonda Herring
Student 21056764

2. 2
Acknowledgement
This critical literature review is dedicated to my mother, father, son and daughter for
offering me the encouragement, confidence and determination to succeed in my
nursing studies. Without their support in understanding the sacrifice of my quality
time with them in order to complete my studies and write this dissertation, I could
never have accomplished this quest.
My thanks are also extended to the University of West London’s lecturers Mrs.
Yvonne Morris and Mr. Dave Sookhoo for their advice extended to me in researching
this subject area. Finally, I would like to thank my fellow university colleagues for
providing a welcoming environment in which to study for the past three years and a
superb mentor from a previous placement area for their feedback and comments
regarding the nature of this paper: postoperative pain management.

3. 3
Contents
Page
Abstract 5
Chapter One 6
1.1 Introduction 6
1.2 Background 7
1.3 Aim 9
1.4 Rationale 9
1.5 Search Strategy 10
Chapter Two 13
2.1 Specific Aims of the Studies 13
2.2 Design, Setting and Sample Size 14
2.3 Methodology Quality & Limitations 15
2.4 Key Findings 18
Chapter Three 19
3.1 Discussion Overview 19
3.2 Pain Assessment and Documentation 19
3.3 Patient Education and Communication 22

4. 4
3.4 Attitudes of Nurses 21
3.5 Administration of Analgesics 24
3.6 Time Constraints/Busy Nurses 24
3.7 Integrating Knowledge into Practice 25
3.8 Implications for Practice 26
3.9 Conclusion 30
Reference List 31
Appendices 38
4.1 Literature Search 38
4.2 Data Extraction Table 39
4.3 Letts et al Qualitative Assessment Tool 41
4.4 CASP Mixed Methods Evaluation Tool 42

5. 5
Abstract
Effective postoperative pain management endeavours to prevent the negative effects
of pain and should enhance the patient’s recovery and wellbeing. Despite the
introduction of clinical practice guidelines and the availability of effective analgesics,
adult postoperative pain management remains problematic and many patients
continue to suffer on hospital wards. Nurses spend extensive time caring for patients
on surgical wards and are required to act professionally and ethically in the patient’s
best interests and as the patient’s advocate. Adverse postoperative complications
arise from poorly managed pain which causes delayed wound healing, an inability of
the patient to function and is associated with depression and anxiety, as well as
prolonged hospital stays. Therefore, the role of nurses in reducing postoperative
pain is pivotal to positive patient outcomes - physically and psychologically. Nurses
are responsible for assessing and documenting the patient’s pain postoperatively
and possess the autonomy to decide whether to administer prescribed pain-reducing
analgesics and subsequently monitor the effect of this medication.
This literature review appraises and scrutinises the findings of six studies focused to
the role of nurses in effectively assessing and managing postoperative pain in adult
patients undergoing general surgery requiring a hospital stay. The pain management
practice of nurses throughout the studies was found to be consistently poor. Barriers
to nurses’ effectively managing postoperative pain included: inaccurate pain
assessment, poor nurse-patient communication, time constraints, a lack of
knowledge and patient education, difficulties integrating knowledge into practice and
the challenge of organisational change in National Health Service (NHS) hospitals.
Although the failure globally to manage postoperative pain has long been
documented, innovative ways must be sought to make improvements through further
training and effective leadership which shares responsibility and encourages nurses
to enhance their practice of postoperative pain management.
Keywords: postoperative pain, nursing assessment, patient satisfaction, health
knowledge/attitudes.

6. 6
Chapter One
1.1 Introduction
Inadequate postoperative pain management presents a problem globally and has
been documented throughout the literature for decades (Bardiau et al 2003; Bedard
et al 2006). The National Health Service (NHS) conducts around 4.2 million
operations annually, which equates to one procedure for every 12 people (Royal
College of Surgeons [RCS], 2010), yet significant deficits have been found in the
management of postoperative pain throughout NHS hospitals (Clinical Standards
Advisory Group 2000; McDonnell et al 2003). Surgery causes tissue damage which
results in expected pain postoperatively and presents as severe pain for 10-50 per
cent of patients due to inadequate pain relief (Kehlet et al 2006; Royal College of
Anaesthetists 2010). Poorly managed pain interferes with postoperative
complications to pose adverse health risks including: delayed mobilisation, venous
thrombo-embolisms, sleep deprivation, distress and anxiety (ESRA, 2008).
Consequently, the patient’s recovery is compromised due to delayed wound healing,
a poor experience of the surgery undertaken and a prolonged hospital stay (Royal
College of Surgeons, 2012; European Society of Regional Anaesthesia 2008; British
Pain Society 2007). Uncontrolled postoperative pain can also easily progress into
chronic pain and is strongly linked to depression, despair and a loss of faith in the
nursing care received (McCaffery et al, 2011; Bell and Duffy 2009). Given these
facts, reducing post-surgical pain is imperative for patient wellbeing – both physically
and psychologically.
Pain is a humanitarian matter and therefore nurses are ethically obliged to reduce
patient suffering – a failure to do so is cited by some as “torture” (Cox 2010; Ferrell

7. 7
2005; Vickers 2009). Nurses spend a considerable amount of time caring for
patients postoperatively compared to other health professionals and are therefore in
a prime position to accurately assess and manage patients’ pain. Nurses also
possess the autonomy to decide whether to administer pain-relieving analgesics,
many of which are prescribed on an “as required” basis (Manias 2006; Pasero et al
2007). Using their clinical judgement regarding the administration of pain relieving
medications, nurses must ensure patients receive appropriate doses that do not
result in under-medication (Sloman et al, 2005).
1.2 Background
From the introduction of anaesthesia in 1847, pain management has supported the
humanitarian obligation of providing care that benefits patient well-being, reduces
suffering and promotes good (Ferrell, 2005). The International Association for the
Study of Pain (IASP) is the world’s largest organisation dedicated to pain research
and improving treatment. They launched the Global Year Against Acute Pain in
2010, ranking postoperative pain as the number one cause of acute pain. Due to the
global failure in eradicating postoperative pain, the Report of the Working Party on
Pain after Surgery (1990) acknowledged pain is extensive and difficult to treat, as it is
“a subjective, emotional experience” (Melzack and Wall, 1996) which is “whatever
the person experiencing it says it is and says it does” (McCaffery 1983, p.14). New
guidelines were issued by the European Society of Regional Anaesthesia (ESRA,
2008) and the Royal College of Anaesthetists (RCA, 2003) to improve nurses’
standards of postoperative pain management as an essential component to quality
practice. Additionally, the Department of Health (DOH) NHS Plan (2000) which
pledges to “get the basics right”, introduced guidance for postoperative pain

8. 8
management in the Essence of Care benchmark on Pain (2009). Yet despite
increased focus to this area, the management of postoperative pain “remains
problematic” as many patients continue to suffer postoperatively on hospital wards
(Abdalrahim et al, 2011; Lamdin and Shaw, 2011). In a further bid to reduce patient
suffering, there are demands for postoperative pain to become the “fifth vital sign”
(Cox 2010; Vickers 2009; Ferrell 2005).
Nursing embraces the humanistic approach to patients´ subjective pain experiences
with the objective of providing physical and emotional comfort (McLeod, 2007).
Furthermore, nurses must act ethically as their patients’ advocates in assessing and
documenting pain accurately (NMC, 2008). Orlando’s Deliberative Nursing Process
Theory (1990) placed emphasis on nurse-patient interaction, validating the
perceptions made and uses the nursing process to provide positive outcomes for
patients. Pain assessment commences the process of pain management. By
incorporating pain rating and verbal descriptor scales, pain can be accurately
quantified and documented (ESRA, 2008), yet nurses appear to adopt different
approaches and attitudes towards assessing pain. Although nurses have an ethical
duty to acknowledge patients’ reports of pain (RCA, 2003), there are allegations that
nurses form their own selective judgements of patients’ pain (McCaffery et al 2011;
Abdalrahim et al 2011; Cantrill et al 2004). These suggestions bring into question
nurses’ overall understanding of postoperative pain management as these imply
nurses are unable to implement their theoretical knowledge into practice (Dihle 2006;
Wood 2010; Powell et al 2009; Berg and Idvall 2008).

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1.3 Aim
This review aims to explore the effectiveness of nurses in managing adult
postoperative pain following general surgical procedures. The intention is to
examine how nurses conduct postoperative pain management and their approach
towards this, integrating patient perceptions where possible for comparison. This is
vital to gain a thorough understanding of pain experiences and to ascertain whether
nurses are delivering humanistic care that reduces patient suffering and provides
effective postoperative pain management.
The subject question formed for this literature review is: are nurses effectively
managing postoperative pain in adult patients undergoing general surgery?
The PICO framework was employed to structure the question as essential phrases
associated with the subject are utilised to obtain an accurate answer to the question
(National Institute of Clinical Excellence, 2009):
P= Population: Postoperative adult patients
I = Intervention: Effective pain assessment and management of nurses
C = Comparator: Patient experience and barriers to effective practice
O = Outcome: Reduced pain and positive patient outcome
1.4 Rationale
Rationale for this review stems from a personal interest in postoperative pain
management after having witnessed questionable practice across pre-registration
placements. As pain is an individualised experience, its very nature necessitates
nurses deliver personalised, patient-centred care. In fact, personalised postoperative

10. 10
care is very much patient-centred as its focus is to meet the individual pain needs of
the patient. Effective patient-centred care is the integral vision of the NHS Plan
(2000) which aims to deliver “high quality care for all” (Department of Health, 2008)
and is set out in new directives by the Health and Social Care Bill (2011). Extended
hospital stays cost the NHS around £400 per day per patient, without considering the
cost of further clinical interventions involved in treating complications which arise
from poorly managed pain (NHS Institute for Innovation and Improvement, 2008).
There may be the general misconception that postoperative pain management has
improved due to the introduction of new guidance and Acute Pain Services, yet a UK
survey revealed 60 per cent of patients suffered severe pain postoperatively (Moss et
al, 2005). Scarce research relating to postoperative pain management has been
conducted in the UK and there appears to be a lack of national consensus or clear
understanding of its importance (Powell et al, 2009). That said, patients have the
right to receive competent, evidence-based care from nurses which recognises and
acknowledges the patient’s opinion of their pain as the specialist, expert opinion
(Hunter, 2000).
1.5 Search Strategy
An electronic literature search of the healthcare databases Medline, Cinahl and
Science Direct was conducted to obtain the best available research underpinning
evidence based practice. Cinahl is a comprehensive nursing database, whilst
Medline is the United States’ National Library of Medicines, offering in excess of 16
million records. Relevant keywords to the health topic were used: postoperative
pain, nursing assessment, patient satisfaction and health knowledge/attitudes.
Boolean logic allowed keywords to be combined by selecting the option “and”. When

11. 11
merging postoperative pain “and” nursing assessment, this produced literature
specific to the review question. Due to the vast expanse of results generated,
limitations were applied to set the inclusion criteria to: publications dated 2005 to
present, humans, adults aged 19 years upwards and English language. However,
caution was exercised to ensure relevant articles were not omitted. Filtering the
searches yielded 55 articles but some were excluded because they focused on
pharmacologic interventions rather than the “nursing assessment” of postoperative
pain. The database search is attached in Appendice 1.1.
Seeking quantitative, qualitative and triangulated research (mixed methods) was vital
to project a wide source of evidence and provide a rounded, complete illustration of
how nurses practice postoperative pain management in the clinical setting and to
explain why they may act in a certain manner (Ellis 2011, p.107). Although
randomized-controlled trials are deemed the “gold standard” of clinical research, the
literature searches yielded no trials pertaining to nurses’ practice towards pain
management, only the intervention of pharmacologic treatments. Abstracts were
also read and expert material obtained from specialised journals including: The
Journal of Pain, Pain Management Nursing, Best Practice & Research Clinical
Anaesthesiology and Nurse Education in Practice. Nursing research books were
sourced and read online using Dawsonera through the University of West London’s
library (2012). Studying the reference lists from obtained articles proved beneficial
for providing further evidence to strengthen this review and is described as “snowball
sampling” (Procter et al, 2010). This also allowed a greater understanding of
postoperative pain management and assisted in appraising evidence for inclusion or
exclusion.

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The Critical Appraisal Skills Programme (CASP, 2011) assessment validation tools
were employed to analyse the reliability and validity of quantitative studies and to
determine the rigour and credibility of qualitative research (Guba and Lincoln 1989,
p.138; Ellis, 2010). A data extraction table used to synthesise the articles is attached
as Appendice 5.2 and illustrates key themes pertaining to the effectiveness of nurses
in managing postoperative pain. This also details studies excluded which failed to
meet inclusion criteria. Data extraction is crucial for undertaking a competent
synthesis and quality appraisal of the literature to accurately interpret the results
presented (Khan, 2004).
This chapter has described the importance of postoperative pain management and
the necessity for nurses to demonstrate proficiency in their practice of this. Chapter
two will critically appraise six research articles and analyse their quality to provide
discussion of the key themes emerging from these studies.

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Chapter Two
This chapter will provide an overview of six papers used to answer the review
question and incorporates the aims, designs, methods and key findings of these
studies. Limitations and flaws established through assessing the literature using the
CASP (2011) validation tools will also be discussed to illustrate an in-depth analysis.
It is imperative to point out that all research utilised in this review met stringent
ethical considerations and participant consent was obtained in all instances. Ethics
are crucial in healthcare as nurses must practice in an ethical manner which
continually considers the rights of patients cared for (Ellis 2011; NMC 2008). Much
early nursing research was conducted to the detriment of vulnerable people and little
consideration was paid to ethics. Thus the Declaration of Helsinki (1964) was
introduced to ensure research was of an acceptable standard, causes no harm and
assures participants are respected, confidentiality is preserved and participants grant
full consent (Johnson and Long 2010, p.27).
2.1 Specific Aims of the Studies Used
All studies reviewed had a definitive target population which were postoperative adult
patients requiring a hospital stay following general surgery. Brown & McCormack
(2006) aimed to explore how nurses conducted postoperative pain management in
older patients, examining nursing culture and decision-making as well as patients’
perceptions of their pain and care delivered. The objective of Sloman et al (2005)
was to compare nurses’ pain ratings with patients’ pain reports; whilst Wickstrom et
al (2008) compared patients’ pain rating scales against those documented by nurses
and to ascertain if nurses’ practice of postoperative pain management had improved

14. 14
two years later following an education programme. Gunningberg and Idvall (2007)
studied the quality of nurses’ postoperative pain management in a university hospital
whilst the intention of Dihle et al (2006) was to determine how nurses performed
postoperative pain management and their attitudes towards pain. The final paper by
Powell et al (2009) intended to explore factors that either helped or hindered
postoperative pain management across three NHS acute pain services.
2.2 Design, Setting and Sample Size
Brown and McCormack (2006) undertook a critical ethnography using a sample of 39
nurses and 46 patients aged 65 upwards set in a colorectal unit in Ireland, whilst
Sloman et al (2005) compared the postoperative pain reports of 95 multi-cultural
patients with 95 registered nurses set across 4 hospitals in Israel. Wickstrom et al
(2008) conducted a two-part cross-sectional, descriptive study on two urological
wards in Sweden using prospective surveys with a sample of 22 nurses and 141
patients aged 63 years upwards. Gunningberg and Idvall (2007) conducted a non-
experimental study in Sweden which compared pain assessments from a
convenience sample of 121 patients and 47 nurses using questionnaires. The two
units comprised general surgery and thoracic surgery at a university hospital. Dihle
et al (2006) observed and interviewed a strategic sample of 9 nurses in two
Norwegian hospitals to examine their nursing practice and behaviour; whilst Powell
et al (2009) conducted a case study of three “broadly typical” NHS acute pain
services, incorporating documentary review and 71 semi-structured interviews with
anaesthetists and nurses.

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2.3 Methodology Quality & Limitations
Various methodologies were implemented by the researchers of the studies
synthesised for this review. Four researchers incorporated questionnaires - a
quantitative methodology for which assessing reliability and validity is essential
(Brown and McCormack 2006; Sloman et al 2005; Wickstrom et al 2008;
Gunningberg and Idvall 2007). However, Dihle et al (2006) and Powell et al (2009)
adopted qualitative methodologies for which rigor and credibility is assessed.
Questionnaires have been used to provide a solid method of obtaining perceptions
and opinions for many years (Jones and Rattray, 2010). Although cross-sectional
and strategic sampling ranks lower on the hierarchy of evidence recommended for
clinical research (Sacket et al, 1996), the observation of nursing practice and
integration of personal experiences are crucial for the holistic nature of this review.
Observation also serves to illustrate first-hand accounts of behaviours and events to
gain a deeper insight into nurses’ practice in reality (Watson et al, 2010).
Brown and McCormack (2006) triangulated methods by combining ethnography with
the Nursing Work Index Revised questionnaire, observation, recorded semi-
structured patient interviews and field notes. Large samples are not an intrinsic
feature of qualitative areas of research due to the insistence that results lose their
significance in greater numbers (Ellis, 2011). Despite this, it was disappointing that
only 46 out of 108 patients participated, which demonstrated a large drop-out and
questioned the reliability. Additionally, results from this specialised colorectal unit
cannot be easily transferred to general surgery; therefore a larger sample and
general surgical setting is preferable to add power to the findings and improve
generalisation. However, two analysts confirmed rigour by ensuring all areas of

16. 16
research were exhausted and used Cronbach’s alpha statistical analysis to assure
reliability and minimise bias (Atkinson and Delamont, 2006).
Sloman et al’s (2005) descriptive comparative study utilised the validated Short Form
McGill Pain questionnaire and a demographic questionnaire. Nurses were not privy
to patients’ pain reports and independently rated their perceptions. The sample size
met minimum criteria of 63 participants per group to feasibly allow transferability to
the target population (Polit and Hungler 1999, p.492). Patients were trained in using
the pain scales to ensure true reflections of their pain were presented. Nurses were
also proficient in using these, which added confidence in the results (Griffiths and
Rafferty, 2010, p.412). Data was statistically analysed using SPSS and Pearson’s
correlation tool. However, it was disappointing that all nurses were employed from
hospitals in Jerusalem as they were not representative of Israel’s entire population;
sampling from across Israel would have provided better generalisation.
Wickstrom et al (2008) used cross-sectional sampling and employed surveys for data
collection. Cross-sectional samples are drawn from populations for which the
exposures are prevalent - relevant for researching postoperative pain management.
Although surveys are a popular tool to explore feelings and attitudes, data is
collected simultaneously which renders them ineffective for illustrating a sequence of
events (Ellis, 2011, p.93). The small sample of 22 nurses in part II also limited this
study. As the questionnaire was not validated its reliability was questionable, but
SPSS analysis and Fisher’s Test measured these to assure internal reliability and
validity. As data was collected in 2004, it is queried why the study was published
only in 2008 - a possible argument for publication bias.

17. 17
The non-experimental design adopted by Gunningberg and Idvall (2007) seemed
wholly appropriate for studying nursing efficacy (Fitzpatrick-Lewis, 2009). The
Strategic and Clinical Quality Indicators in Postoperative Pain Management
questionnaire was validated and provided transferable results as the sample was
appropriate to the target population (Jones and Rattray, 2010, p.369). Used
previously, the questionnaire possessed good psychometric properties and was
reproducible which contributed to greater ‘precision’ in its measure (Saw and Ng,
2001). However, as questionnaires struggle to detail specifics of importance to
patients; incorporating qualitative interviews could provide greater insight.
Dihle et al (2006) conducted interviews and observed 9 nurses’ postoperative pain
management practice using two researchers to ensure all areas of research were
exhausted. Trustworthiness and authenticity was assured by combining the
interviews, field notes and observations and established rigor (Ellis, 2011). The
extremely small sample size limits its transferability but the setting provided valid
information and therefore can be generalised to other surgical wards (Ellis, 2011,
p.55).
Powell et al (2009) adopted an interpretivist approach in the first case study to date
to examine problems posed in improving postoperative pain management throughout
NHS pain services. Case study research tackles complex, real-life issues using a
holistic approach (Clarke and Reed, 2010, p.238). A previous pilot study paved the
way for proficient data collection undertaken by one researcher who recorded and
transcribed 71 semi-structured interviews with clinical staff and nurses (Lacey, 2010,
p.23). The settings were generally typical of NHS hospitals and as findings were
presented transparently, this allowed transferability which is often debatable in

18. 18
qualitative research. Rigour and credibility was assured by the use of inductive and
deductive content analysis and was imperative as no previous studies of this nature
had taken place (Topping, 2010).
2.4 Key Findings
Results from all six research papers presented consistent themes to suggest nurses’
management of postoperative pain was insufficient. These highlighted poor pain
assessment and poor pain documentation by nurses as major areas of concern.
Also to emerge was an absence of patient education and nurses’ apparent lack of
the ability to integrate knowledge into practice. These themes will be explained in
detail in Chapter Three as the discussion to this literature review.

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Chapter Three
This chapter will focus on the discussion of prevalent themes to emerge from the
literature review and offers additional evidence-based research to support the
findings. Explanation of the key themes intended to answer the review question and
implications for practice are included to offer recommendations for improving the
future practice of nurses in managing postoperative pain.
3.1 Discussion Overview
This critical literature review has objectively questioned the effectiveness of nurses in
assessing and managing postoperative pain in adult patients undergoing general
surgery. From studying research undertaken in the UK, Ireland and Europe,
consistent themes emerged to conclude that nurses’ practice of postoperative pain
management was generally unsatisfactory. The key findings are broken down below
to provide an in-depth explanation of the problems posed in achieving successful
nursing practice of postsurgical pain management.
3.2 Pain Assessment and Documentation: The “Fifth Vital Sign”
Pain assessment is crucial for obtaining optimal postoperative pain relief and is a
fundamental component prior to commencing pain-reducing treatments and
monitoring their effects (McGuire 1992; ESRA 2008; Royal College of Anaesthetists
2010; British Pain Society 2007; IASP 2010). It is clear that successful pain
assessment is pivotal to the patient’s recovery and to achieving the NHS pledge of
“getting the basics rights” (NHS Plan, 2000). However, all papers concluded that
nurses’ management of postoperative pain was unsatisfactory, highlighting poor pain
assessment as a major factor. In fact, one researcher cited the failure of nurses to

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systematically assess pain as the “most common reason for inappropriate pain
management” (Dihle et al, 2006). Although nurses claimed to assess pain
frequently, in practice this was found to be irregular, disorganised and lacking a
uniform approach to the task (Dihle et al, 2006). This is indeed argued by many
researchers as constituting a gap between saying and doing (Clabo 2007; Manias
2005; Cox 2010). Furthermore, whilst some nurses assessed pain by directly asking
patients, others assumed that if patients did not request analgesics they were pain-
free (Brown and McCormack 2006; Dihle et al 2006). Medication rounds were the
mainstay of pain assessment in an Irish study and took place at the end of patient
beds with no consideration for those hard of hearing; hence conversations became
common knowledge (Brown and McCormack, 2006). It is highly worrying that pain
assessment was omitted in some elderly patients, with nurses proceeding to younger
clients instead (Brown and McCormack 2006; Powell 2009). Many argue that this is
a frequent occurrence in hospitals (The British Geriatrics Society 2007; Schofield
2008; Aubrun and Marmion 2007). Furthermore, Swedish general surgical patients
experienced severe pain on day three postoperatively as nurses did not assess pain
and subsequently, the hospital failed to meet its quality goals (Wickstrom et al,
2008).
Many nurses also confessed to not using pain rating scales when assessing pain
(Dihle et al, 2006). One study reported only 41 per cent of patients had pain
documented (Gunningberg and Idvall, 2007) whilst another claimed 40 per cent of
nurses did not use pain scores (Wickstrom et al, 2008). This is consistent with
findings from many studies (Moss et al 2005; Cox 2010; Manias 2005; Carr et al
2005; Schofield 2008, British Pain Society 2007). Previously, the National
Confidential Enquiry into Perioperative Deaths (1999) reported that the majority of

21. 21
older patients did not have pain records documented. However, two-thirds of NHS
hospital beds are occupied by older adults, many of whom undergo emergency
surgery due to falls (Department of Health, 2001). Pain documentation forms an
essential aspect of patient care and provides a precise record of the nurse’s
professional competence (McGuire 1992; Manias 2003; Wood 2010). In taking the
steps to document pain, nurse-patient communication is improved and facilitates
personalised pain management according to the patient’s individual needs (de Rond
et al, 2001). Nevertheless, nurses must correctly use pain scales in order to interpret
pain accurately but many researchers argue these are beneficial only if followed up
with pain-relieving interventions (Bell and Duffy 2009; Carr 2005; Manias et al 2006).
Health trusts increasingly employ pain assessment scales to ensure that nurses
assess pain and document it correctly; the failure to use these may be construed as
negligence and implies nurses are ignorant to the importance of documenting pain
(Schafheutle et al, 2001).
Nurses did not reassess pain prior to or during mobilisation despite patient
complaints, yet research indicates activities are extremely painful postoperatively so
this is a significant oversight on the part of nurses (Chen and Herr 2009; Moss et al
2005; Chung and Lui 2003; Manias 2006; Royal College of Anaesthetists, 2010;
IASP 2010). Generally, pain was only reassessed in patients receiving intravenous
analgesics and disregarded those on oral medications (Dihle et al 2006; Wickstrom
et al 2008; Gunningberg and Idvall 2007). However, Good Clinical Practice
Guidelines (ESRA, 2008) stipulate that nurses should continually reassess and
document pain after administering pain-relieving medications to monitor its efficacy.

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3.3 Patient Education and Communication
Excellent nurse-patient communication is crucial for assessing pain, deciding
treatments, educating patients and to extract patient fears regarding analgesics and
dependency (Wood 2010; Vickers 2009). Communicating effectively encourages
patients to become actively involved in their care, builds trust in nurses and results in
improved patient wellbeing - vital as pain is subjective and individualised (McGuire
1992; McCaffery 1983; Melzack and Wall 1996). Patients overwhelmingly expressed
they wanted involvement in their pain management and guidance regarding pain-
reducing treatments, yet none was provided (Brown and McCormack 2006; Dihle et
al 2006; Gunningberg and Idvall 2007). This correlates with previous claims of 60
per cent of patients receiving no advice from nurses (Manias, 2006). It is important
to point out that previous research suggests the majority of patients are unaware of
how effective analgesics can be and perceive pain as inevitable following surgery,
further compounded by their fears of opioids (Chung and Lui 2003; Crawford et al
2011). It therefore seems obvious that patients must be well informed by nurses
regarding pharmacologic and non-pharmacologic pain treatments available to them
(Hunter 2000; ESRA 2008; British Pain Society 2007).
3.4 Attitudes of Nurses
Patients have the right to be acknowledged as experts concerning their pain and this
necessitates nurses both recognise and accurately reflect the patient’s report of pain
(Hunter, 2000). The patient’s self-report of pain is gold standard for effective
postoperative pain management, particularly following demands for pain to become
“The Fifth Vital Sign” (British Pain Society and British Geriatrics Society, 2007).
However, many nurses employed in NHS hospitals viewed postoperative pain

23. 23
management as unimportant (Powell et al, 2009). The attentiveness of nurses to
visual indications of pain varied: whilst some were sensitive to this, others
disregarded and chose to ignore their patients’ pain (Wickstrom et al 2008; Dihle et al
2006; Sloman et al 2005; Brown and McCormack 2006). Patients also complained
that nurses adopted a “one size fits all” attitude towards pain relief or disbelieved
their reports of pain (Brown and McCormack 2006, Sloman et al 2005; Dihle et al
2006). Furthermore, nurses significantly under-estimated pain in comparison to
patients’ reports which suggests nurses doubt their patients’ accounts of pain. This
was prevalent throughout the papers and has been found in previous research
(Sloman 2005; Wickstrom et al 2008; Brown and McCormack 2006; Dihle et al 2006;
Gunningberg and Idvall 2007; Moss et al 2005; Cox 2010). Despite an educational
programme focused on enhancing postoperative pain management, nurses’ attitudes
had not improved after two years and severe pain remained under-estimated
(Wickstrom et al, 2008). This apparent negative attitude can perhaps be linked to
suggestions that nurses do not prioritise pain assessment, perceiving pain to be
acceptable postoperatively and believing patients exaggerate their pain intensities
(Manias et al 2005; Clabo 2007; Abdalrahim 2007; Sloman et al 2005; Wood 2010;
Cox 2010; Bozimowski 2010; Idvall and Berg 2008; Niemi-Murola et al 2007).
Therefore, allegations of nurses forming personal and selective judgements of
patients’ pain appear to be solid and factual (Dihle et al 2006; McCaffery et al 2011;
Abdalrahim et al 2011; Cantrill et al 2004). Conflicting patients’ and nurses’ reports
of pain must therefore result in a lack of agreement on pain-relieving treatments,
particularly as documented pain dictates whether patients will receive analgesics
(Wickstrom et al, 2008). When combined with irregular pain assessment and

24. 24
infrequent monitoring of pain following interventions, these discrepancies also render
clinicians unaware as to whether treatments are proving effective (Carr et al, 2005).
3.5 Administration of Analgesics
A large number of patients suffered pain postoperatively on hospital wards - as
alleged in previous research (Abdalrahim et al 2011; Lamdin and Shaw 2011; Cox
2010). Additionally, many nurses did not administer the correct combinations of
prescribed analgesics, under-medicated with lower doses and rarely administered
oral opioids (Dihle et al 2006; Brown and McCormack 2006; Sloman et al 2005). As
many analgesics are prescribed on an “as required” basis, it is imperative that nurses
ensure they administer doses that do not result in under-medication of patients and
combine treatments in order to provide patients with optimum pain relief (Dihle et al
2006; Sloman et al 2005; ESRA 2008; McCaffery et al 2011).
3.6 Time Constraints/Busy Nurses
Nurses consistently faced constant interruptions when assessing pain which
hindered their practice of postoperative pain management (Brown and McCormack
2006; Sloman et al 2005; Dihle et al 2006; Wickstrom et al 2008; Gunningberg and
Idvall 2007; Powell 2009). A lack of time due to staff shortages and increased
workloads is argued as the most common barrier to nurses’ effectively managing
pain (Manias et al 2005; Schafheutle et al 2001). Due to this fact, older patients felt
disempowered and were reluctant to discuss their pain for fear of hindering busy
nurses or being perceived as a “nuisance” (Wickstrom et al 2008; Dihle et al 2006),
as previously established (Schofield 2008; Manias 2005; McDonald et al 2000;
Ferrell 2005). Staff shortages and time constraints undoubtedly disrupt the ability of
nurses to effectively manage pain, but this is also problematic for nurses and outside

25. 25
the realms of their control (Wickstrom et al 2008; Manias et al 2005). This noticeable
lack of time is clearly a deterrent for older patients to report their pain and is
complicated further by a general reluctance among this age group to discuss pain
due to the traditional British “stiff upper lip” and a belief that “good patients do not
discuss pain” (Schofield 2008; Aubrun and Marmion 2007). This increases the
complexity of pain management in elderly patients within the UK and frequently
results in under-recognised and under-treated postoperative pain (Bedard et al 2006;
British Pain Society and British Geriatrics Society 2007). Despite the pressure of
time constraints and under-staffing, nurses have a duty to recognise older patients’
reluctance to report pain and persist with patience when assessing pain to provide
beneficial pain relief (Aubrun and Marmion 2007; Barkin et al 2005).
3.7 Integrating Knowledge into Practice
Nurses possessed theoretical knowledge of the importance to assess pain and
provide patient education but seldom put this into practice (Dihle et al 2006;
Wickstrom et al 2008; Brown and McCormack 2006). A tendency of nurses to
“dump” responsibility of the patient onto acute pain services when pain became
difficult to manage may be associated with fears of over-medicating due to potential
patient risks and professional accountability (Brown and McCormack 2006; Powell et
al 2009; Moss et al 2005; Wood 2010; Crawford et al 2010). As patients tend to fear
side-effects from painkillers, worries from both parties can form a vicious circle which
deters nurses from integrating knowledge into practice. Nurses also appear to lack
knowledge, motivation and a trust in their capabilities from colleagues which prevents
them from effectively managing postoperative pain (Moss et al 2005; Clabo 2007;
Bozimowski 2010). Nurses throughout NHS hospitals were concerned about

26. 26
overstepping their professional boundaries and the internal politics caused by power
struggles among multi-disciplinary teams hindered their ability to manage pain
(Powell et al, 2009). A need for further training to develop their knowledge and gain
clarity of their roles in managing postoperative pain has been expressed by 44 per
cent of nurses earlier to this review (Niemi-Murola et al, 2007). From an
organisational perspective, it is regrettable that most nurses offered training were
unable to attend due to immense workloads and staff shortages (Powell et al, 2009).
Additionally, instilling cultural change to improve postoperative pain management
across the hospitals seemed insurmountable due to acute pain teams struggling to
engage commitment from surgical nurses (Powell et al, 2009).
3.8 Implications for Practice
Effective postoperative pain management strives to prevent the negative effects of
pain and should facilitate patient recovery (Arslan and Celebioglu, 2004). This is vital
as uncontrolled postoperative pain detrimentally interferes with the patient’s ability to
function and causes serious post-surgical complications (ESRA 2008; RCA 2010;
British Pain Society 2007). Postoperative pain management is therefore a significant
factor when considering the patient’s recovery and wellbeing in order to enable
discharge from hospital. Nurses are obliged professionally and ethically to deliver
superior postoperative care by using the best available evidence to manage pain by
acknowledging the patient’s report of pain and reflecting the patient’s individual
needs (RCA 2003; ESRA 2008; British Pain Society 2007; NMC 2008). Patient-
centred care forms the integral vision of the NHS Plan (2000) which pledges to “get
the basics right” and improve patients’ experiences of their care. Regrettably, this
review has ascertained that nurses’ are not meeting their obligations to successfully
manage postoperative pain and are clearly failing to “get the basics right”.

27. 27
It is recommended nurses improve pain assessment by adopting a uniform, direct
approach with patients, employing validated pain rating scales to ease the process
and continuously document pain scores in patient notes. To successfully assess
pain, nurses must adjust their attitudes towards pain management and develop their
knowledge to consider the needs of all postoperative patients (Brown and
McCormack 2006; Manias 2005; Schofield 2008; Cox 2010; Wood 2010). Particular
attention is required when assessing the pain of elderly patients who are often
deemed a “challenge” due to co-existing diseases, a reluctance to report pain and
cognitive impairments which complicates the communication process (British Pain
Society and British Geriatrics Society 2007; Barkin et al 2005; Brown and
McCormack 2006; Dihle et al 2006; Schofield 2008). There also appears to be a
clear lack of understanding among nurses and an absence of a national consensus
for improving postoperative pain management in NHS hospitals (Powell et al, 2009).
Therefore, organisational commitment as well as nursing dedication is required to
engage a collaborative approach to effectively challenge current pain management
practices and drive forward change (Brown and McCormack 2006; Powell et al 2009;
Gunningberg and Idvall 2006; Wickstrom et al 2008).
Orlando’s Deliberative Nursing Process Theory (1990) emphasises that the nurse-
patient relationship commences with patient assessment which should be used in
conjunction with pain rating scales before and after pain-reducing treatments, and
documented to accurately reflect the patient’s pain (Bedard et al 2006; Chen and
Herr 2009). However, nurses’ reports of pain were viewed as being of greater
importance than patients’ accounts and were frequently the deciding factor as to
whether patients would receive analgesics. This illustrates the impact documented
pain has on clinical decision-making and the subsequent medication administration

28. 28
by nurses (Berg and Idvall 2008; Cantrill et al 2004; Carr et al 2005; Manias et al
2006). Nurses were generally reluctant to administer prescribed combinations of
analgesics due to a fear of over-medicating or causing detrimental side effects
(Brown and McCormack 2006; Dihle et al 2006; Cox 2010). To eradicate this
problem, anaesthetist-led education programmes could be offered to surgical nurses
to increase their knowledge in administering safe levels of analgesics. The Royal
College of Anaesthetists (2010) states “education is a key factor in the provision of
effective pain management” and therefore changing nurses’ clinical practice and
attitudes is reliant upon the provision of quality education and training. Current
recommendations specify that ongoing training must be made available to all staff
caring for postoperative patients to address pain assessment, communication skills
and pain-relieving treatments (RCA, 2010). These recommendations insist that
trusts allocate funding for this and demands that nurses are released from their
duties to attend pain management training. This is encouraging as the majority of
nurses interviewed throughout NHS hospitals disclosed they were rarely able to
attend due to staff shortages (Powell et al, 2009). Further postoperative pain
management training is vital to improve communication skills and offer nurses
strategies for encouraging reluctant patients to disclose their pain, which also assists
in nurses demonstrating compassion towards patients’ suffering (RCA 2010;
Wickstrom et al 2008).
Patient education postoperatively was poor so instilling the necessity in nurses to
effectively provide this would increase patient knowledge and lead to greater patient
satisfaction (Bozimowski, 2010). Senior nurses may demonstrate sound leadership
skills by using a collaborative, transformational approach to welcome input from their
nurses as to how they can better educate postoperative patients about their pain

29. 29
(MacLellan, 2004). Additionally, the Department of Health’s NHS Leadership
Academy (2012) clearly stresses that innovative leadership improves patient
outcomes and increases staff satisfaction in the process of change. Adopting a
motivational technique could prove invaluable as nurses recognise their opinions are
valued which in turn raises their incentive to improve pain management practice
(Thompson, 2012). Subsequently, through raising nurses’ self-esteem, they may
become more receptive to welcoming patients to participate in their postoperative
care which improves the surgical experience for patients as they recognise their
“voice” is heard (Kouzes and Posner 2009; Genton et al 2009; Mortlock 2011).
Pain-reducing treatments were seldom discussed with patients, including non-
pharmacologic treatments, yet the significant benefit of these interventions is the
ability to implement these when analgesics are unsuitable (Arslan and Celebioglu,
2004). With this in mind, therapies such as massage, relaxation, hot or cold
compresses, transcutaneous nerve stimulation and distraction techniques could be
considered to further reduce pain and improve nurses’ overall practice of
postoperative pain management (Yildizeli-Topcu and Yildiz-Findik, 2012). Relaxation
exercises have been found to be highly beneficial in reducing pain on days one and
two postoperatively, particularly when combined with prescribed analgesics (Friesner
et al 2006; Good et al 2006). Furthermore, relaxation has been proven to ease
anxiety and tension caused by postoperative pain by reducing blood pressure,
breathing rate and heart rate. This could prove to be of assistance in maintaining
patients’ vital signs within safe limits (Kesler et al, 2003).

30. 30
3.9 Conclusion
From conducting this critical literature review, the findings overwhelmingly and
consistently concluded that the effectiveness of nurses in managing adult
postoperative pain is unsatisfactory. High quality care for all is a prerequisite of the
Department of Health (2008, 2001) and therefore, the delivery of postoperative pain
management should meet the expectations of all surgical patients. Many NHS
hospitals display posters which claim they are achieving the vision of the NHS Plan
(2000) in “getting the basics right”; in fact all hospitals local to the author of this
review exhibit these with pride. The NHS Next Stage Review (Department of Health,
2008) stipulates its objective is to ensure “high quality care for all” which entails the
delivery of superior, personalised healthcare for all patients. In the specific words
published:
The NHS Next Stage Review makes a compelling case that it can deliver high
quality care for patients in all respects.
Fundamentally, this report stresses that it is the quality of care that matters the most
to patients. It further emphasises that patients require assurances that care
delivered will be tailored to their individual needs, they will be treated with
compassion and respect when in hospital and will receive effective treatments.
Although progress has undoubtedly been made in many areas of healthcare, it would
appear from the findings of this literature review that nurses’ practice of managing
postoperative pain in NHS hospitals requires significant improvement.

31. 31
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38. 38
5.0 Appendices
5.1 Electronic Literature Search

39. 5.2 Data Extraction Table adapted from Timmins and McCabe (2005)
First Author,
Journal, Year,
Location
Study Design
Type of
Study
Purpose Sample
Met
inclusion
criteria,
ethics
Data
Collection
Key Findings
Confirm/
Disprove
Author
Hypothesis?
1
Brown, D.,
Journal of
Clinical
Nursing, 2006,
UK
Ethnography,
non-participant
observation,
interviews,
Nursing Work
Index
questionnaire
Qualitative
and
Quantitative:
questionnaire
Mixed-
Methods
Determining factors
that have an impact
upon effective
evidence-based pain
management with
older people
following colorectal
surgery
85
Yes and
ethical
approval
obtained,
written
consent
obtained
Ely (1991) 10
step qualitative
analysis,
SPSS
computed
Poor assessment –
disbelieved patients.
Poor communication.
No patient education.
Nurses interrupted.
Confirm
2
Sloman, R.,
Journal of
Advanced
Nursing, 2005,
Israel
Questionnaire Quantitative
Nurses’ assessment
of pain in surgical
patients
190
Yes and
ethical
approval
gained,
consent
gained.
Computed,
SPSS,
Pearson
Correlation
Nurses under-estimated
patients’ pain.
Nurses interrupted.
Confirm
3
Wickstrom, K.,
Journal of
Clinical
Nursing, 2008,
Sweden
Cross-
sectional,
descriptive
survey
Quantitative
Postoperative pain
management –
influence of surgical
ward nurses
163
Yes,
University
Hospital
approval,
informed
consent.
Computed,
SPSS, survey
40% not use pain
scales.
Poor documentation.
Poor assessment, no
evaluation.
Overestimated mild and
Under-estimated severe
pain.
Lack of knowledge into
practice.
Confirm

40. 40
4
Gunningberg,
L.,
Journal of
Nursing
Management,
2007, Sweden
Descriptive,
non-
experimental,
questionnaires
Quantitative
The quality of
postoperative pain
management from
the perspectives of
patients, nurses and
patient records
168
Yes,
Research
Ethics
Committee
approval,
written
consent.
Computed,
Chi-Square
Poor assessment –
41% patients regularly
assessed.
Nurses under-estimated
patients’ pain.
Poor documentation.
Confirm
5
Dihle, A.,
Journal of
Clinical
Nursing, 2006,
Norway
Descriptive,
non-participant
observation,
interviews
Qualitative
The gap between
saying and doing in
postoperative pain
management
9
Yes and
ethical
approval
obtained,
written
consent
obtained
Kvale (1996)
hermeneutic
process of
qualitative
analysis
Poor assessment
evaluation.
Not use pain scales.
Lack of knowledge into
practice.
Poor communication.
No patient education.
Confirm
6
Powell, A.,
British Journal
of
Anaesthesia,
2009,
UK
Case study,
interviews,
documentary
review
Qualitative
Challenge of
improving
postoperative pain
management:case
studies of three
acute pain services
in the UK National
Health Service
71
Yes,
Research
Ethics
Committee
approval,
written
consent.
Previous pilot
study
conducted,
Interviews
recorded and
transcribed
Many unconvinced
postoperative pain was
important or
improvements needed.
Internal politics around
responsibilities hindered
POP.
No training for
improving practice.
Tendency to shift
responsibility to APS.
Confirm
7
Bozimowski,
G.,Pain
Management
Nursing
Descriptive,
narrative
Qualitative
Patient Perceptions
of Pain Management
Therapy
39
No,
excluded
as not
detailed
Interviews
Nurses under-estimate
pain, poor pain
assessment
Excluded,
unpublished

41. 5.3 Letts Qualitative Assessment Validation Tool

42. 42
5.4 Critical Appraisal Skills Programme Mixed Methods Evaluation Tool