Journal of Gerontological Nursing

Nursing Knowledge: ACUTE POSTOPERATIVE PAIN MANAGEMENT IN THE ELDERLY

Dorothy Y Brockopp, RN, PHD; Sherry Warden, RN, PHD; George Colclough, MD; Gene Wm Brockopp, PHD

Abstract

INTRODUCTION

The inadequate management of acute postoperative pain (APP) among adults is well documented (Bonica, 1980; Cohen, 1980). Studies have shown that 75% or more of hospitalized adult patients following surgery suffer moderate or intense pain even with the use of analgesics (Keeri-Szanto, 1972; Ketuvuori, 1987; Marks, 1973). Physicians underprescribe narcotic analgesics and nurses administer less than the patient could receive (Lisson, 1 987). The attention given to relief of postoperative pain is minimal in relation to other parameters of physical well-being, such as vital signs and urine output. Evidently, complications that can occur as a result of unrelieved pain are poorly understood (Knight, 1978).

Even though elderly patients (individuals over age 65) are more likely to have chronic illnesses resulting in pain, and are less likely to receive needed pain medication, little attention has been given to the management of pain within this population (Ferrell, 1990; Herr, 1991). Although most researchers and clinicians agree that ineffective management of pain is associated with lack of knowledge, few systematic investigations of caregiver's knowledge levels regarding pain management of elderly patients have been conducted.

This study was undertaken to assess the level of knowledge of practicing nurses and senior nursing students regarding the pain management of elderly patients. Both the practicing nurses and the senior nursing students graduated from the same baccalaureate nursing program. Differences in knowledge level between the two groups also were assessed.

REVIEW OF LITERATURE

Although the physician is responsible for designing the overall pain management plan, nurses are responsible for the following:

* Continuously assessing the patient's comfort level;

* Alerting the physician should comfort levels change;

* Taking nursing actions when appropriate; and

* Reporting any side effects experienced from treatment for pain (McCaffery, 1989).

Across populations, nurses' ineffective approaches to the management of pain have been attributed to inappropriate fears of addiction and respiratory depression, rigid attitudes regarding what constitutes adequate pain relief, and misunderstandings about the physiologic and psychologic components of pain.

From a questionnaire and chart reviews of 109 postoperative patients, Cohen (1980) discovered that patients were receiving less analgesia than they could have received and that nurses were inappropriately concerned about the possibility of addiction. Ninety-seven percent of the nurses caring for these patients indicated that complete pain relief was not their goal; 45% of the patients stated that their pain was severe enough to cause them to cry out.

Table

RESULTS

A significant difference was found between practicing nurses and senior nursing students on knowledge level (t=4.25, p<.001). The mean knowledge score for practicing nurses was 23.7 (SD = 2.7); the mean was 21.7 (SD = 2.5) for senior nursing students.

Although there were too few nurses with graduate preparation and too few nurses who attended continuing education programs on pain management to statistically analyze the data, demographics regarding these parameters are presented in Table 1. Table 2 presents the means and standard deviations of nurses with and without graduate degrees and nurses who did and did not attend continuing education programs on pain management.

The following items were answered incorrectly by the majority of both groups; more than 50% of nurses and nursing students did not agree with the following statements:

* A painful state following surgery is unhealthy and often dangerous;

* Postoperative pain can be relieved in the majority of cases;

* Following an intraoperative nerve block (eg, an epidural), the tendency for patients is to ask for pain medication later than if they had received general anesthesia;

* If confusion exists, an assessment of pain is still of value;

* If analgesics are ordered every 4 hours, it…

INTRODUCTION

The inadequate management of acute postoperative pain (APP) among adults is well documented (Bonica, 1980; Cohen, 1980). Studies have shown that 75% or more of hospitalized adult patients following surgery suffer moderate or intense pain even with the use of analgesics (Keeri-Szanto, 1972; Ketuvuori, 1987; Marks, 1973). Physicians underprescribe narcotic analgesics and nurses administer less than the patient could receive (Lisson, 1 987). The attention given to relief of postoperative pain is minimal in relation to other parameters of physical well-being, such as vital signs and urine output. Evidently, complications that can occur as a result of unrelieved pain are poorly understood (Knight, 1978).

Even though elderly patients (individuals over age 65) are more likely to have chronic illnesses resulting in pain, and are less likely to receive needed pain medication, little attention has been given to the management of pain within this population (Ferrell, 1990; Herr, 1991). Although most researchers and clinicians agree that ineffective management of pain is associated with lack of knowledge, few systematic investigations of caregiver's knowledge levels regarding pain management of elderly patients have been conducted.

This study was undertaken to assess the level of knowledge of practicing nurses and senior nursing students regarding the pain management of elderly patients. Both the practicing nurses and the senior nursing students graduated from the same baccalaureate nursing program. Differences in knowledge level between the two groups also were assessed.

REVIEW OF LITERATURE

Although the physician is responsible for designing the overall pain management plan, nurses are responsible for the following:

* Continuously assessing the patient's comfort level;

* Alerting the physician should comfort levels change;

* Taking nursing actions when appropriate; and

* Reporting any side effects experienced from treatment for pain (McCaffery, 1989).

Across populations, nurses' ineffective approaches to the management of pain have been attributed to inappropriate fears of addiction and respiratory depression, rigid attitudes regarding what constitutes adequate pain relief, and misunderstandings about the physiologic and psychologic components of pain.

From a questionnaire and chart reviews of 109 postoperative patients, Cohen (1980) discovered that patients were receiving less analgesia than they could have received and that nurses were inappropriately concerned about the possibility of addiction. Ninety-seven percent of the nurses caring for these patients indicated that complete pain relief was not their goal; 45% of the patients stated that their pain was severe enough to cause them to cry out.

Table

TABLE 1Age, Education Level, and Attendance at Continuing Education (CB) Programs on Pain

TABLE 1

Age, Education Level, and Attendance at Continuing Education (CB) Programs on Pain

Strauss (1974) found that nurses had preconceived ideas regarding the degree of pain that was appropriate given a particular procedure or diagnosis. When patients' behaviors deviated from this imposed norm, nurses had difficulty responding to patients' needs. Other studies showed that nurses were more likely to infer that pain was a reality when physical pathology was evident, and that nurses found a moderate level of pain reduction adequate unless a patient was experiencing severe pain (Taylor, 1984).

A number of studies have been conducted to examine nurses' knowledge regarding the management of adult cancer pain. Findings suggest that many nurses lack knowledge about basic concepts related to the management of cancer pain. Myers (1985) collected data on knowledge of treatment for cancer pain from 67 nurses. Thirty-six percent of the nurse subjects agreed that cancer patients receiving around-the-clock narcotics were at risk for drug addiction. Given specific situations, 43% inappropriately feared patient sedation and respiratory depression.

Fox (1982) examined the medical records of 30 cancer patients and found that patients frequently received as-needed medications that exceeded the pharmacologic duration of the drug. Nurses did not regularly assess patients' comfort levels and had misconceptions regarding narcotic addiction that led to ineffective management of pain. A general lack of knowledge among nurses related to opioid analgesic drugs and psychologic dependence was identified by McCaffery and associates (1990).

Donovan (1983) interviewed 96 randomly selected cancer patients from four medical and four surgical units. Fifty percent of the patients were in mild to moderate levels of pain; 43% of the patients could recall having a nurse discuss pain with them. Pain was identified as a problem on only 28% of the patients' care plans.

Knowledge deficits among nurses related to APP are thought to result from inadequate education. According to the literature that evaluates nursing care provided for APP, nurses' lack of knowledge regarding the management of pain is not being addressed within practice institutions (Taylor, 1984). Although educational institutions also have been criticized for not emphasizing the management of pain within curricula, most nursing curricula and nursing adult health texts do address various aspects of pain management. The question of how well student nurses learn to manage pain and whether this knowledge is transferred into the practice setting has not been addressed.

In relation to the elderly, characteristics of this population that may lead to even less effective pain management are of considerable concern. For example, elderly patients have been found to complain of pain less than other age groups and are less inclined to request increases in pain medication (Barth, 1982). These two characteristics alone could put this group of patients in an even more vulnerable position than their younger counterparts.

PURPOSE OF THE STUDY

The purpose of this study was to examine the following:

* The level of knowledge regarding pain management of the elderly among senior nursing students;

* The level of knowledge regarding pain management of the elderly among practicing nurses; and

* The difference in knowledge levels between nurses in practice and nursing students in their last year of formal education.

Given the large number of elderly who are affected by cancer, specific questions regarding the management of cancer pain were addressed. It was hypothesized that nurses in the practice environment would score higher on a knowledge test than senior nursing students.

METHOD

Sample

In order to test the difference in knowledge between practicing nurses and student nurses, a minimum sample size of 128 subjects was predetermined to give a power = .80, at a .05, effect size = .50. All senior nursing students and practicing nurses who fit the eligibility criteria were asked to participate in the study. Ninety-six percent (n = 65) of practicing nurses and 100% (n = 70) of student nurses returned questionnaires.

The eligibility criterion for the senior nursing students was that they had to be 4-year students pursuing a baccalaureate degree in nursing. Eligibility criteria for the practicing nurses were that they had to practice in an acute care setting for 2 or more years, regularly provide care for elderly patients undergoing surgery (minimum of once a week), and graduation from the same program as the student nurses. Two years was selected as a minimum number of years in order for the practicing nurse to have time to learn from peers and to attend available continuing education offerings.

Eight of the practicing nurses were between the ages of 20 and 25, 35 were between 26 and 35, and 22 were between 36 and 50. Fifty eight of the student nurses were between the ages of 20 and 25, 7 were between 26 and 35, and 2 were between 36 and 50. All the practicing nurses had a baccalaureate degree, 10 had their master's and 1 had a doctorate. Fifteen of the practicing nurses had attended one or more continuing education programs on the management of pain.

Table

TABLE 2Means and Standard Deviations of Knowledge Seuroores (Highest Possible Score = 30)

TABLE 2

Means and Standard Deviations of Knowledge Seuroores (Highest Possible Score = 30)

Setting

The study took place at a large southeastern state university. Students were recruited from a baccalaureate program in their last semester of school. Practicing nurses were recruited from the University Hospital, a 500-bed tertiary care center that served a large rural and urban population.

Instruments

An investigator-designed instrument, the Acute Postoperative Pain Inventory: Elderly Patients, was used to collect the data. Items were developed from the literature on the elderly and the literature on pain management. Content validity was established by 4 nurse investigatorclinicians in pain management, a psychologist (director of a pain management center), and an anesthesiologist who worked with postoperative pain management. The questionnaire contained 30 items, with possible scores ranging from 0 to 30. The phrase "among elderly patients following surgery" preceded each item. An a coefficient of .44 was calculated on 134 subjects.

Procedure

A research assistant (with no connection to either the University Hospital or the College of Nursing) explained the study to potential subjects and provided an envelope for them to return completed questionnaires. No names were associated with the questionnaires.

Table

TABLE 3Percentage of Correct Responses by Student and Practicing Nurses to a Knowledge Questionnaire on Pain*

TABLE 3

Percentage of Correct Responses by Student and Practicing Nurses to a Knowledge Questionnaire on Pain*

Table

TABLE 3Percentage of Correct Responses by Student and Practicing Nurses to a Knowledge Questionnaire on Pain*

TABLE 3

Percentage of Correct Responses by Student and Practicing Nurses to a Knowledge Questionnaire on Pain*

RESULTS

A significant difference was found between practicing nurses and senior nursing students on knowledge level (t=4.25, p<.001). The mean knowledge score for practicing nurses was 23.7 (SD = 2.7); the mean was 21.7 (SD = 2.5) for senior nursing students.

Although there were too few nurses with graduate preparation and too few nurses who attended continuing education programs on pain management to statistically analyze the data, demographics regarding these parameters are presented in Table 1. Table 2 presents the means and standard deviations of nurses with and without graduate degrees and nurses who did and did not attend continuing education programs on pain management.

The following items were answered incorrectly by the majority of both groups; more than 50% of nurses and nursing students did not agree with the following statements:

* A painful state following surgery is unhealthy and often dangerous;

* Postoperative pain can be relieved in the majority of cases;

* Following an intraoperative nerve block (eg, an epidural), the tendency for patients is to ask for pain medication later than if they had received general anesthesia;

* If confusion exists, an assessment of pain is still of value;

* If analgesics are ordered every 4 hours, it is inappropriate for nurses to instruct patients in pain to wait until their medication is due;

* Patients' reports of pain are better indicators of narcotic dosage than height and weight;

* Elderly cancer patients who are on a morphine drip can stay on the medication even though euphoria develops;

* Nonsteroidal anti-inflammatory drugs (NSAIDs) are not the drugs of choice for moderate to severe pain;

* The elderly can experience as much pain as other age groups;

* The physician is not solely responsible for the management of postoperative pain; and

* Meperidine is shorter acting and more toxic than morphine.

Responses to all items by both groups are included in Table 3.

DISCUSSION

Practicing nurses did score higher than student nurses on the pain questionnaire; however, it is disconcerting to note that both groups did not appear to understand some basic tenets of pain management. The results of this study support McCaffery's (1989) finding that nurses do not understand the effective use of narcotics in relation to pain management. In addition, both groups did not understand confusion among the elderly as it relates to pain assessment as well as other important components of pain assessment with this population.

The results of this study strengthen the concern previously expressed in the literature regarding the lack of education of nurses regarding the effective management of APR Effective control of pain through use of narcotics must be clearly conveyed to both students and practicing nurses. Myths regarding the elderly relative to their experience of pain should be clarified. It also would seem that modifications to nursing curricula in educational institutions and programs of continuing education in acute care settings relative to pain management are in order.

REFERENCES

  • Barth, J. The influence of age on pain and pain relief in postsurgical patients. Unpublished master's thesis, the University of Illinois Medical Center, Chicago, 1982.
  • Bonica, J.J. Pain research and therapy: Past and current status and future needs. In L.K.Y. Ng, J.J. Bonica (Eds), Proceedings of the National Conference on Pain, Discomfort and Humanitarian Care. New York: Elsivier, 1980, pp. 1-47.
  • Cohen, J. Postsurgical pain relief: Patients' status and nurses' medication choices. Fain 1980; 9:299-314.
  • Donovan, B.D. Patient attitudes to postoperative pain relief. Anesthesiology Intensive Care 1983; 11:125-129.
  • Ferrell, B.A., Ferrell, B.R., Osterweil, D. Pain in the nursing home. J Am Geriatr Soc 1990; 38:409-414.
  • Fox, L. Pain management in the terminally ill cancer patient: An investigation of nurses' attitudes, knowledge, and clinical practice. Mil Med 1982; 147:455-460.
  • Herr, K.A., Mobily, P.R. Complexities of pain assessment in the elderly: Clinical considerations. Journal of Gerontological Nursing 1991; 17(4):12-19.
  • Keeri-Szanto, M., Heaman, S. Postoperative demand analgesia. Surgical Gynecology and Obstetrics 1972; 134:647-651.
  • Ketuvuori, H. Nurses' and patients' conceptions of wound pain and the administration of analgesics, journal of Pain and Symptom Management 1987; 2(4):213-218.
  • Knight, C.L. Postoperative pain relief. Br J Hosp Med 1978; 19:462.
  • Lisson, E. Ethical issues related to pain control. Nurs Clin North Am 1987; 22(3):649659.
  • Marks, R.N., Sacher, E.J. Undertreatment of medical inpatients with narcotic analgesics. Ann Intern Med 1973; 78:1586-1591.
  • McCaffery, M., Beebe, A. Pain: Clinical manual for nursing practice. St. Louis: C.V. Mosby, 1989.
  • McCaffery, M., Ferrell, B., O'Neil-Page, E., Lester, M., Ferrell, B. Nurses' knowledge of opioid analgesic drugs and psychological dependence. Cancer Nurs 1990; 13(1):2127.
  • Myers, J.S. Cancer pain: Assessment of nurses' knowledge and attitudes. Oncol Nurs Forum 1985; 12(4):62-66.
  • Strauss, E., Fagerhaugh, S. Y., Glasser, B. Pain: An organizational-work-interactional perspective. Nurs Outlook 1974; 22:560-566.
  • Taylor, A.G., Skelton, J.A., Butcher, J. Duration of pain condition and physical pathology as determinants of nurses' assessments of patients in pain. Nurs Outlook 1984; 33(1):4-8.

TABLE 1

Age, Education Level, and Attendance at Continuing Education (CB) Programs on Pain

TABLE 2

Means and Standard Deviations of Knowledge Seuroores (Highest Possible Score = 30)

TABLE 3

Percentage of Correct Responses by Student and Practicing Nurses to a Knowledge Questionnaire on Pain*

TABLE 3

Percentage of Correct Responses by Student and Practicing Nurses to a Knowledge Questionnaire on Pain*

10.3928/0098-9134-19931101-08

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