INTRODUCTION: Post-operative pain is associated with poor patient satisfaction and severe complications. It is often underreported and poorly managed. The aim of this study was to investigate which factors influence and prevent optimal pain treatment according to healthcare providers.
METHODS: We conducted an electronic questionnaire survey, which was distributed by e-mail to 364 doctors, nurses, dentists and social and healthcare assistants employed at the emergency and surgical departments of Zealand University Hospital, Koege, Denmark. The 15-item-questionnaire investigated which factors influenced pain treatment.
RESULTS: A total of 124 of 364 (34%) healthcare providers completed the questionnaire. The four primary factors influencing pain treatment were sufficient time, interdisciplinary cooperation, patient involvement and staff education. The two primary barriers preventing optimal pain treatment were a high level of activity at the ward (40%) and a lack of knowledge (33%).
CONCLUSIONS: Time, staff education, interdisciplinary cooperation and patient involvement were the primary factors influencing pain treatment. Insufficient time and limited knowledge on the part of the healthcare providers were the greatest barriers preventing good pain treatment
in everyday practice.
TRIAL REGISTRATION: not relevant.
Post-operative pain is often accompanied by fatigue, nausea and vomiting, leading to impaired pulmonary function, delayed convalescence and occasionally chronic pain [1, 2]. There is an association between patient satisfaction and self-reported pain on a numerical rating scale [3, 4]. Therefore, patient satisfaction and pain management should be cornerstones for healthcare providers.
Despite heightened awareness of pain management, little or no improvement of post-operative pain was
detected in an American patient survey conducted twice at a two-decade interval . This raises the question: Which barriers prevent efficient pain treatment?
A Danish observational study on pain management from Rigshospitalet highlighted several issues. The authors reported lack of registered pain data, procedure-specific guidelines and non-opioid pain treatment in clinical practice . Furthermore, lack of knowledge may also prevent optimal pain treatment [7, 8].
Healthcare providers play a central role in patients’ pain treatment. Accordingly, identifying obstacles they need to overcome to improve pain treatment is important. The aim of this study was to investigate which factors influence and prevent optimal pain management according to healthcare providers.
This questionnaire study was conducted at Zealand University Hospital, Koege, Denmark. No person-sensitive data from respondents or patients were recorded. Therefore, approval by the Scientific Ethics Committee and the Danish Data Protection Agency was not required. This manuscript adheres to the CHEck list for Reporting Results of Internet E-Surveys (CHERRIES) . The participants were informed about the expected time consumption of the survey, the identity of the investigators and the purpose of the study. The questionnaire was developed specifically for the study, as no suitable pre-existing questionnaire was found. The
electronic questionnaire was made using Survey-Xact (Rambøll A/S, Aarhus, Denmark). Fifteen doctors and nurses with different levels of education and competences tested and validated the questions. The questionnaire was distributed on 8 November 2017. A reminder was sent to non-respondents after 15 November 2017. Responses received after 15 December 2017 were excluded. We planned to include all surgical departments and the emergency department. The Department of Orthopaedic Surgery declined to participate.
The electronic questionnaire was sent by e-mail to 364 doctors, nurses, dentists and social and healthcare assistants employed at the Department of Abdominal Surgery; the Department of Oto-rhino-pharyngeal Surgery; the Department of Oral and Maxillofacial surgery; and the Emergency Department. The survey was voluntary and available only when a link had been provided. No incentives were offered. Ongoing responses were saved by the system, and respondents could edit their answers before final submission. The survey results were accessible only to the investigators. The questionnaire consisted 15 items and could be submitted only upon completion of all questions.
The questionnaire consisted of statements to which participants indicated their agreement on a Likert scale (Not at all, Low degree, Somewhat or Highly) or a 0-10 scale (0 = no knowledge, 10 = highest possible level of knowledge). Questions were answered by ticking boxes with predefined answers or by entering free text.
Data were managed using Microsoft Excel Version 2013.
Trial registration: not relevant.
Of the 364 distributed questionnaires, 124 were completed, yielding a response rate of 34% (Table 1). A total of 15 questionnaires were invalid.
The four primary factors influencing sufficient pain treatment were time, interdisciplinary cooperation, patient involvement and staff education (Figure 1). The two most common barriers identified that prevented the healthcare professionals from providing sufficient pain treatment was a high level of activity at the ward (40%) and a lack of knowledge (33%) (Figure 2).
The majority (79%) found that the pain treatment was “somewhat” efficient at their department.
The mean self-reported knowledge on pain treatment was rated six on a 0-10 scale. There was general agreement that the level of knowledge left room for
improvement. There was a multitude of different approaches to establishing knowledge about pain treatment. Most respondents found pain treatment to be a team responsibility (85%) and that the patients should be highly involved (80%) (Table 2).
The questionnaire revealed that sufficient time, staff education, interdisciplinary cooperation and patient involvement were the key factors listed by the respondents for establishing efficient pain treatment.
In everyday practice, a high level of activity at the ward and a lack of staff knowledge were the primary barriers.
Limited time was also recognised as a key factor in a large British survey including 180 nurses  who reported workload and a lack of staff as the reasons for sub-optimal pain management, thus supporting our findings. Lack of adequate time during rounds may prevent individual assessment of the nature and degree of pain experienced by the patients.
A large Danish survey revealed that only few data on pain score were available in the patient charts at the surgical departments . To ensure that attention is
given to the issue, pain has been proposed as the fifth vital sign . Once pain is adequately recognised and assessed, it is – naturally – easier to treat. Time is also identified as an important factor from the patients’ perspective. Patient satisfaction increased when nurses had the time to address patients’ pain and had a short response time to complaints of pain .
The high level of activity at the wards will likely prove difficult to solve in the near future.
A questionnaire study including 386 American physicians revealed a lack of knowledge, especially about the risk of psychological dependency from opioids . The authors reported that physicians’ attitudes
directly inhibited the pain treatment by interfering with the appropriate prescribing of pain-relieving medications. When assessing pain, nurses rely to a large extent on their own judgement of patients’ non-verbal behaviour, which has been shown to systematically underestimate patient-perceived pain [8, 10].
It pays off to educate staff and patients about pain. An American survey found that educating nurses in pain behaviour, side effects and interventions relating to pain improved nursing knowledge. The education programme was part of an algorithm that also comprised patient education. The combined algorithm produced an increase in patient satisfaction . Introducing such an algorithm can be very complex and often time consuming.
A systematic review investigated the effectiveness of online pain resources for health professionals.
The results show that the participants who received E-learning had a significantly greater knowledge and better skills than those receiving training as usual . E-learning may be more feasible to implement than other types of training and can be performed whenever convenient.
Eighty percent of the respondents in this survey stated that patients should be highly involved in their own pain treatment. Pain after surgery is the main concern for patients when interviewed prior to surgery . Hence, a randomised controlled trial revealed that patient education was associated with lower anxiety
levels preoperatively and a more rapid decline in pain after surgery . A large survey from 51 clinical centres in 17 countries showed that increasing patient involvement produced a higher level of patient satisfaction .
By educating patients in pain treatment, they are empowered to become actively involved in their own treatment which, in turn, improves patient satisfaction and outcomes [4, 14].
Eighty-five percent of the respondents in our survey found pain treatment to be a team responsibility. Interdisciplinary cooperation is a key element in the fast-track surgery concept. Ideally, anaesthesiologist, surgeons, nurses and physiotherapists should be involved in pain treatment [1, 6].
Acute pain services often take a multidisciplinary approach. Several trials have shown that implementing an acute pain service leads to improved pain treatment . An acute pain service may handle complex pain patients, supervise epidural pain treatments, develop procedure-specific pain treatment for post-operative pain, and be responsible for teaching and training the healthcare providers in evidence-based pain management .
Strengths and limitations
Our study has several limitations. The response rate was only 34%, which is less than satisfactory. Looking at the respondents, we found that one third answered regardless of their profession, which makes the validity for doctors and nurses stronger than for social and healthcare assistants and dentists.
The low response rate may increase the risk of non-response bias. For instance, the busiest employees may have been too busy to respond, thereby causing an underestimation of the importance of sufficient time.
The questionnaire was performed in a single hospital in Denmark, which may limit the external validity of our results.
In this survey, healthcare providers indicated that sufficient time, staff education, interdisciplinary cooperation and patient involvement were the primary factors influencing pain treatment. A high level of activity at the ward and limited staff knowledge were acknowledged as the primary barriers preventing good pain treatment in everyday practice.
CORRESPONDENCE: Josephine Zachodnik.
ACCEPTED: 18 December 2018
CONFLICTS OF INTEREST: none. Disclosure forms provided by the authors are available with the full text of this article at Ugeskriftet.dk/dmj
Kehlet H, Dahl JB, Anaesthesia, surgery, and challenges in postoperative recovery. Lancet 2003;362:1921-8.
Brix LD, Bjørnholdt KT, Thillemann TM et al. Pain-related unscheduled contact with healthcare services after outpatient surgery. Anaesthesia 2017;72:870-8.
Gan Tj, Habib AS, Miller TE et al. Incidence, patient satisfaction, and perceptions of post-surgical pain: results from a US national survey. Curr Med Res Opin 2014;30:149-60.
Mathiesen O, Thomsen BA, Kitter B et al. Need for improved treatment of postoperative pain. Dan Med J 2012;59(4):A4401.
Moore RA, Straube S, Aldington D. Pain measures and cut-offs – “no worse than mild pain” as a simple, universal outcome. Anaesthesia 2013;68:400-12.
D Glowacki. Effective pain management and improvements in patients’ outcomes and satisfaction. Crit Care Nurs 2015;35:33-41.
Jacobsen R, Sjogren P, Moldrup C et al. Physician-related barriers to cancer pain management with opioid analgesics: a systematic review. J Opioid Manag 2007;3:207-14.
Drayer RA, Henderson J, Reidenberg M. Barriers to better pain control in hospitalized patients. J Pain Symptom Manage 1999;17:434-40.
Eysenbach G. Improving the quality of web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res 2004;6:e34.
Schafheutle EI, Cantrill JA, Noyce PR. Why is pain management suboptimal on surgical wards? J Adv Nurs 2001;33:728-37.
Purser L, Warfield K, Richardson C. Making pain visible: an audit and review of documentation to improve the use of pain assessment by implementing pain as the fifth vital sign. Pain Manag Nurs 2014;15:137-42.
Gordon DB, Polomano RC, Pellino TA et al. Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) for quality improvement of pain management in hospitalized adults: preliminary psychometric evaluation. J Pain 2010;11:1172-86.
Weinstein SM, Laux LF, Thornby JI et al. Physicians’ attitudes toward pain and the use of opioid analgesics: results of a survey from the Texas Cancer Pain Initiative. South Med J 2000;93:479-87.
DeVore J, Clontz A, Ren D et al. Improving patient satisfaction with better pain management in hospitalized patients. J Nurse Pract 2017;13:e23-e27.
Liossi C, Failo A, Schoth DE et al. The effectiveness of online pain resources for health professionals. Pain 2018;159:631-43.
Sjöling M, Nordahl G, Olofsson N et al. The impact of preoperative information on state anxiety, postoperative pain and satisfaction with pain management. Patient Educ Couns 2003;51:169-76.
Schwenkglenks M, Gerbershagen H, Taylor R et al. Correlates of satisfaction with pain treatment in the acute postoperative period: results from the international PAIN OUT Registry. Pain 2014;155:1401-11.
Werner MU, Søholm L,Rotbøll-Nielsen P et al. Does an acute pain service improve postoperative outcome? Anesth Analg 2002;95:1361-72.