Most patients undergoing surgery have some pain experience (Gerbershagen et al., 2013). In fact, approximately 70% of postsurgical cardiovascular patients experience moderate to severe pain (Parizad et al., 2014). Cardiovascular surgery pain is unique for a variety of reasons, including multiple incision sites, chest tube insertion sites, and multiple lines and drains. The pain a patient experiences occurs from multiple origins: bones, muscles, nerves, and ligaments (Hamid et al., 2015). Following cardiac surgery, patients are taken to the intensive care unit (ICU) for continuous monitoring, where approximately 77% of patients experience pain (Parizad et al., 2014). Given that the pain after cardiovascular surgery stems from multiple origins, a high risk for inadequate pain control exists (Mueller et al., 2000). If pain is inadequately controlled in postsurgical cardiovascular patients, those recovering may exhibit an increased heart rate, respiratory rate, blood pressure, and sleep disturbances (Parizad et al., 2014). Consequences of inadequate pain control can lead to further postsurgical complications and delayed healing (Miller et al., 2007). Preventing complications and improving outcomes postsurgery are directly related to adequate pain management (Bonnet & Marret, 2007; Gan, 2017; Pogatzki-Zahn et al., 2017).
The recovery for patients after cardiac surgery is currently “fast-tracked.” This newer method for postcardiac surgery recovery became the standard of care in the early 2000s and has led to an increased problem in pain control for this group of patients. Strategies included in the fast-track program for cardiac surgery are early extubation, shorter ICU stays, and discharge to home within 3 to 5 days (McKee et al., 2007). Since this time line became the standard practice, the pain management patients receive intraoperatively is affected, which in turn affects their postoperative pain management (White et al., 2007). Pain management starts with the anesthesiologist; therefore, with the use of the fast-track method, induction of anesthesia uses a lower dose of narcotics and postoperative sedation management is weaned more quickly than conventional anesthesia (Ranjan & Ramachandran, 2016). By comparison, conventional anesthesia uses high doses of narcotics, as well as muscle relaxers (Probst et al., 2014). By weaning sedation and narcotic medications sooner, patients are able to be extubated more quickly, but that often comes at the expense of adequate pain control in the immediate postoperative period. The fast-track method encourages early mobilization and activities to promote earlier discharge to home, which can greatly increase a patient's pain if not managed appropriately. Although there continues to be new pain management techniques and advances, ensuring adequate pain management following cardiac surgery using the fast-track method can be difficult (Milgrom et al., 2004).
Nurses' Knowledge of and Attitudes Toward Pain Management
Pain is a subjective experience that each individual perceives in a unique way. Therefore, adequate pain management can be a challenging task. In postoperative cardiovascular patients, nurses have identified that lack of knowledge regarding pain creates a barrier to providing optimal patient care (Watt-Watson & Stevens, 1998). Areas that have been identified as knowledge deficits in pain management include pain terminology, the physiology of pain and patient's subjective pain experience, and pharmacologic and nonpharmacologic pain management options (Margonary et al., 2017).
The personal attitudes of nurses toward pain can have a direct impact on pain management of patients. Siedlecki et al., (2014) revealed that nurses often have negative attitudes towards patients with chronic pain, patients requiring often hospitalizations and patients who voice chronic dissatisfaction with pain measures. Leegaard et al. (2011) found that it is not only the nurses' attitudes toward pain but also the patients' attitudes that affect the adequacy of their pain management in the hospital. Factors such as the patient's age, culture, and beliefs about opioids and addiction have the highest impact on pain management (Leegaard et al., 2011). These feelings, along with a lack of knowledge, contribute to the undertreatment of pain in the inpatient setting (Hartog et al., 2010; Siedlecki et al., 2014).
Another aspect of postoperative pain management is caring for patients with opioid tolerance. Opioid-tolerant patients require additional knowledge for adequate pain management and an unbiased attitude. When caring for patients with previous opioid use, misconceptions have been identified that lead to poor pain management. Coluzzi et al. (2017) uncovered four common misconceptions: misunderstanding of maintenance therapy, additional opioids leading to addiction relapse, increased adverse effects with additional opioids, and patient-controlled analgesics being considered as unsuccessful for opioid-tolerant patients. One overwhelming theme found in the literature was maintaining a nonjudgmental attitude when caring for opioid-tolerant patients in the acute care setting (Coluzzi et al., 2017; Cooney, 2015).
Current Quality Improvement Project
The aim of this quality improvement project was to assess the effects of an educational intervention on nurses' knowledge and attitudes toward pain management in care rendered to patients recovering from cardiovascular surgeries. The educational in-services were given during routine staff meetings and lasted approximately 10 minutes; these were offered a total of eight times and at least once during every shift in the unit over a period of 2 weeks by the same individual for consistency. This individual had been employed in this unit and collaborated with the other members of the research team, who were experienced nurse educators. The content of the presentation was discussed and vetted by the entire team. The staff meetings used to present the in-service education occurred at shift change and were presented to the oncoming nurses in the unit (at 3:00 a.m., 7:00 a.m., 3:00 p.m., and 7:00 p.m.). The advantages of a brief in-service presentation, including the ability to present the material during a regular meeting time for nurses, to reach more nurses outweighed a more formal presentation, which would have required nurses to come in on their own time instead of during normal work hours.
A total of 74 nurses attended the educational in-service. The preeducational survey responses were used to best prepare for the in-service. The in-service content began with an overview of cardiovascular specific pain and the pathophysiology of pain (Hamid et al., 2015). Next, postoperative pain management guidelines (Chou et al., 2016) and the pharmacokinetics of various pain medications were discussed. Finally, patient teaching and discharge education were addressed (Centers for Disease Control and Prevention, 2016). A handout was created and given to each nurse who attended the in-service to reinforce the in-person presentation. Extra handouts and printouts of the in-service presentation slides were left in the break room for nurses who were unable to attend an in-service. After the in-service education was completed, the unit manager again sent an email with the postsurvey link and instructions to answer the same Nurses' Knowledge and Attitudes Survey Regarding Pain (NKASRP) (Ferrell & McCaffery, 2014). Nurses were asked to respond within 1 week.
Design and Measure
Data were collected from a pre- and posteducation survey using the NKASRP (Ferrell & McCaffery, 2014). The survey was given to a convenience sample of postoperative cardiovascular nurses via an online survey prior to and after delivery of in-service education. The Institutional Review Board of Purdue University and Lutheran hospital deemed the quality improvement project exempt status.
A widely used tool to assess knowledge and attitudes of nurses regarding pain is the NKASRP (Ferrell & McCaffery, 2014). The NKASRP is a 39-item questionnaire composed of true-or-false questions (items 1 through 21), multiple choice questions (items 22 through 35), and two case studies (items 36 through 39). The reported Cronbach's alpha for the tool's measure of internal reliability for attitudes and knowledge is r > .70 (Ferrell & McCaffery, 2014). The content validity of the tool has been established through the review of pain experts. Additionally, the construct validity has been established by comparing results of the survey to nurses at various levels of expertise (Ferrell & McCaffery, 2014). Nurses' attitudes toward pain are intertwined with the knowledge questions. Ferrell and McCaffery (2014) advise users of the survey to not distinguish between knowledge and attitudes questions, as many of the questions assess both simultaneously. This tool has been used to evaluated nurses on a variety of settings, including medical–surgical, oncology, geriatric palliative care, and long-term care units (Al-Shaer et al., 2011; Jones et al., 2004; McMillan et al., 2000; Perri et al., 2018). The results of these studies revealed that nurses lack adequate knowledge about pain and score below the standardized passing score of 80% (Ferrell & McCaffery, 2014). The most frequent areas that were missed on these studies involved the pharmacology of pain medications and accurately assessing a patient's subjective pain experience (Al-Shaer et al., 2011; McMillan et al., 2000).
Sample and Setting
The setting for this quality improvement project was a 396-bed tertiary hospital. The hospital, located in a midwestern urban area, is a level II trauma center and is accredited as a chest pain center and heart failure institute (Lutheran Hospital, 2018). The postoperative cardiovascular ICU is a 43-bed unit with 22 intensive care beds and 21 telemetry beds. The nurses care for patients after coronary artery bypass surgery, valve replacement surgery, aortic aneurysm repairs, and a variety of vascular surgeries. The convenience sample included nurses who worked in a postoperative cardiovascular ICU. Participation was voluntary.
The NKASRP (Ferrell & McCaffery, 2014) was offered to respondents as computer-based, online platform (i.e., Qualtrics®). Demographic questions asked were age, ethnicity, and level of education. The survey link and instructions for completing the items were sent by the unit managers to all staff in the unit. No identifying data were collected to ensure anonymity of the responses. The presurvey was open for 4 weeks. After the preeducation surveys were completed, results were analyzed to begin the development of an educational in-service, which focused on areas of weakness identified in the survey results.
The impact of the in-service education was the focus of the data analysis. Data were analyzed using SPSS® and Microsoft Excel®. An independent t test was performed on pre- and posteducation means. Alpha was set at .05.
Of the 82 nurses employed on the postoperative cardiovascular ICU, the response rate for the pre- and posteducation survey was 45% (n = 37) and 42% (n = 35), respectively. Surveys were considered complete and included in the data analysis if the respondent answered at least 70% (27 of 39 items) of the NKASRP tool. In the preeducation survey, a total of 37 RNs responded to the survey, with 59% (n = 22) meeting the threshold for completion. Similarly, a total of 35 RNs responded to the posteducation survey, with 68.5% (n = 24) of those responses being complete. Of the nurses who took the posteducation survey (n = 24), 70% (n = 17) stated they had attended at least one of the educational in-services offered. The majority of the nurses who participated in the survey were ages 25 to 35 years for both the preand posteducation survey (n = 10, n = 10, respectively). Most nurses identified themselves as White in both the pre- and posteducation survey (n = 18, n = 18, respectively). In the preeducation survey, 73% (n = 16) of the RNs who responded held a bachelor's of nursing (BSN) degree, and 18% (n = 4) held an associate in nursing (ASN) degree. The posteducation survey indicated that 83% (n = 20) of nurses who responded had a BSN degree, whereas 4% (n = 1) had an ASN degree.
A passing score, determined by Ferrell and McCaffery (2014), was 80% (31 of 39; range = 0 to 39 points). The t test analysis for pre- and posteducation survey scores revealed significant differences between the two groups (Table 1). An analysis of each question and response correct per question was completed for the pre- and posteducation surveys. For each of the 39 questions, there was an increase in the correct response from the pre- education survey to the posteducation survey, with one exception: the question regarding morphine milligram equivalents (item 17) decreased in correct responses from 59% (n = 13) to 46% (n = 11) in the posteducation survey. The three most frequent correctly and incorrectly answered questions were also compared for the pre- and posteducation surveys (Table 2). Three of the most correctly and incorrectly answered questions were the same in both the pre- and posteducation survey.
Pre- and Posteducation Survey Scores
Three Most Frequent Correctly and Incorrectly Answered Questions
Trends were noted in the two case studies (last four questions of the survey). Case Study A described a patient who was smiling and joking with his visitors and rated his pain at an 8 on a scale of 10. Case Study B described a patient who was grimacing and rated his pain at an 8 on a scale of 10. The first part of the case study was to record how you would rate the patient's pain, and the second part was to determine what action to take based on the patient's pain rating. In the preeducation survey, 55% (n = 12) of participants correctly recorded the patient's pain rating in Case Study A, compared with 92% (n = 22) in the posteducation survey. In Case Study B, 68% (n = 15) of participants correctly recorded the grimacing patient's pain in the preeducation survey and 96% (n = 23) correctly recorded it in the posteducation survey. In the preeducation survey, only 23% (n = 5) of participants correctly determined to administer the correct dose of pain medication based on the physician's order for the patient in Case Study A. This number improved to 58% (n = 14) in the posteducation survey. The largest improvement of correct answers was in Case Study A (item 36), where initially only 55% (n = 12) of participants answered the question correctly, compared with 92% (n = 22) in the posteducation survey.
The purpose of this quality improvement project was to determine the effect of an education in-service on nurses' knowledge and attitudes toward pain management on a postoperative cardiovascular ICU using a convenience sample of nurses. The findings from the preeducation survey revealed there is a knowledge gap in pain management for nurses in the cardiovascular ICU. The largest areas of weakness identified were in pharmacology of pain medications, as well as subjective patient pain experiences (Table 2). These areas of deficit are consistent with previous studies that have been completed to measure nurses' knowledge of pain management (Margonary et al., 2017).
This quality improvement project presents preliminary evidence that providing a brief educational in-service to nurses can be effective and efficient in increasing their overall pain management knowledge. Evidence from literature supports the use of in-service education to increase knowledge and attitudes, but behavior change is less certain (Bluestone et al., 2013). Creating a sustainable, annual in-service for nurses regarding pain management knowledge and attitudes could be one way to increase overall knowledge.
In addition to lecture-based in-service education, research supports the use of interactive education as an effective method of teaching (Bluestone et al., 2013; Chaghari et al., 2017). Because the tool used in this project can be used for future education, developing interactive scenarios can help nurses gain even more knowledge. One specific area of need is in understanding the subjective nature of patient's pain. By creating interactive case studies based on the NKASRP (Ferrell & McCaffery, 2014) tool, which uses incongruent verbal and nonverbal cues, nurses can benefit better from the education and participate in the learning experience. Identifying areas of weakness and the positive effects of pain management education on the survey scores, the necessity of standardized and continuous pain management education for nurses, particularly in the postoperative cardiovascular intensive care unit, is supported.
The quality improvement project results also call for considerations in providing knowledge and clarifying attitudes toward pain management in the orientation phase of nurses who are on-boarding when readiness to learn is high. Acute pain management should be emphasized with the postoperative cardiovascular ICU nursing staff as the country moves toward opioid prescribing guidelines (Centers for Disease Control and Prevention, 2019). As the largest point-of-service providers, nurses are critical to patient satisfaction surveys. This is an especially vulnerable time for health care organizations that are relying on positive patient satisfaction scores to support optimal reimbursement.
The small convenience sample, which was specific to nurses who worked on a cardiovascular ICU, the lack of diversity of the nurses, the modest response rate (45% preeducation, 42% posteducation), and the inability to complete a follow-up survey to determine whether the knowledge was retained are limitations of the quality improvement project. The small sample size and limited project population preclude generalizability. One factor impacting the response rate was a major change in the hospital's charting system that occurred at the time of the first (preeducation) survey deployment. The electronic health record change required nurses to attend classes to learn the new system, which increased their charting time as they adapted to the new system. This may have limited nurses' time to complete the survey.
Adequate and effective pain management education for nurses is needed (Al-Shaer et al., 2011; McMilan et al., 2000; Perri et al., 2018). This quality improvement project revealed that this sample of postoperative cardiovascular intensive care nurses have inadequate knowledge and attitudes regarding pain management, as evidenced by mean score of 62.35% prior to any educational in-service. The posteducational in-service mean score (77%) still fell below the recommended threshold of 80% for the NKASRP survey. However, overall the educational in-services were effective in increasing nurses' knowledge and attitudes regarding pain management in this sample of nurses. Preliminary evidence supports that integrating a brief educational program into the daily routine of nursing care could be beneficial in ensuring nurses are current in their knowledge of how to manage patients' pain.
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Pre- and Posteducation Survey Scores
|Survey||p Value||N||Mean (%)||Range (SD)|
|Preeducation||<0.001||22||24.32 (62.35)||15–32 (5.65)|
|Posteducation||24||30.17 (77.35)||19–37 (5.09)|
Three Most Frequent Correctly and Incorrectly Answered Questions
|Questions Correctly Answered||Correct Responses, n(%)||Questions Incorrectly Answered||Correct Responses, n(%)|
|Preeducation Survey (n= 22)||Posteducation Survey (n= 24)||Preeducation Survey (n= 22)||Posteducation Survey (n= 24)|
|14. Patients' spiritual beliefs may lead them to think pain and suffering are necessary. (True/False)||21 (95)||24 (100)||9. Research shows that promethazine (Phenergan) and hydroxyzine (Vistaril) are reliable potentiators of opioid analgesics. (True/False)||6 (27)||8 (33)|
|15. After an initial dose of opioid analgesic is given, subsequent doses should be adjusted in accordance with the individual patient's response. (True/False)||21 (95)||24 (100)||27. A patient with persistent cancer pain has been receiving daily opioid analgesics for 2 months. Yesterday the patient was receiving morphine 200 mg/hour intravenously. Today he has been receiving 250 mg/hour intravenously. The likelihood of the patient developing clinically significant respiratory depression in the absence of new comorbidity is: (Multiple choice)||3 (14)||10 (42)|
|21. Narcotic/opioid addiction is defined as a chronic neurobiologic disease, characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. (True/False)||21 (95)||24 (100)||35. Following abrupt discontinuation of an opioid, physical dependence is manifested by the following: (Multiple choice)||6 (27)||9 (38)|