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Department of Postoperative and Intensive Care Nursing, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, NorwayMEVU Department, Lovisenberg Diaconal University College, Oslo, Norway
Department of Postoperative and Intensive Care Nursing, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, NorwayMEVU Department, Lovisenberg Diaconal University College, Oslo, Norway
Although Norwegian law requires the documentation of patients’ care processes, including pain assessment, research has shown that the quality of postoperative documentation for assessing pain does not meet an acceptable standard and requires improvement. The purpose of this study was to investigate whether an educational intervention can increase nurses’ documentation of postoperative pain assessments, alter patients’ opioid consumption, and ensure that patients have at least one documented Numeric Rating Scale (NRS) ≤3 at rest before being discharged. A secondary aim was to investigate whether the nurses’ education and experience influenced their pain assessments.
An observational study with a pre-post intervention.
The study following a pre-post design involved documenting pain assessments of 304 patients undergoing cancer surgeries in a postoperative unit at the Norwegian Radium Hospital, Oslo University Hospital. In an educational intervention, two 45-minutes teaching sessions within two weeks, addressed validated pain assessment tools and the documentation of pain assessment. Descriptive frequency analysis and partial correlation with Pearson's r - value were used, with P < .05 indicating significance.
Postintervention, pain assessments in general increased significantly from a mean of two times per patient to three times. Overall, the use of assessment tool Critical -Care Pain Observation Tool increased from 6.1% to 25.8%, opioid consumption increased in mean from 3.34 to 4.79 in milligram and the documentation at discharge increased from 81.4% to 91.4%. The documentation of nurses with more than 10 years’ experience in the unit especially improved from 17.5% to 31.7%.
Educational intervention and reminders about basic systematic pain assessment and the evaluation of pain measures improved nurses’ documentation of postoperative pain management and documentation at discharge. The findings underscore the importance of regularly ensuring the quality of patients’ treatment by systematically documenting nurses’ clinical tasks and the outcome of patients’ care.
A high incidence of pain after surgery (postoperative pain) with inadequate pain management can result in longer hospitalization, increased complications, and may cause a higher risk of developing chronic pain.
Relieving postoperative pain has implications for patients’ well-being, including the reduced psychological aspect of pain, mobilization, and bedtime difficulty as well as the prevention of chronic pain.
Nursing documentation defines the nature of nursing itself by documenting the outcome of patients’ care. No matter how skilled the nurse, poor documentation risks undermining the nurse's credibility in the case of legal action against the nurse or institution.
Optimal pain management – for instance, a numerical rating scale (NRS) score requires pain assessment and the continuous evaluation of measures, in which the reassessment of patients’ pain is an important component.
Thus, the aim of our study was to investigate whether an educational intervention would increase nurses’ documentation of their pain assessments per patient, alter patients’ opioid consumption, and ensure that each patient had at least one documented numeric rating scale (NRS) ≤3 at rest before being discharged. A secondary aim was to investigate whether the nurses' education and experience influenced their pain assessments. By the end of the study, we wanted to have one pain assessment for each patient upon arrival and one upon discharge to ensure quality of patients’ optimal pain management.
Materials and Methods
In our observational study with a pre-post intervention design, the study protocol followed Langley and Nolan's method, which builds on Deming's classic (Plan, Do, Study, Act [PDSA]) cycle, shown in Figure 1.
The plan-do-study-act (PDSA) cycle, with plan occurring in Phase 1 of the study, do in Phase 2, study in Phase 3 and act in Phase 4 and 5, including evaluating the results, sharing the experiences with improvement, and ensuring new practice.
The sample included all eligible patients 18 to 100 years old receiving general anesthesia during abdominal, gynecological, orthopedic, plastic, or urological surgery. All pain assessments were collected from MetaVision, both from the operation theatre and the postoperative unit, before being transferred to general surgical units. Exclusion criteria were patients who had received epidural, spinal, or various nerve blockades or lidocaine - infusion as pain relief in the postoperative unit.
The study was performed at the Norwegian Radium Hospital, Oslo University Hospital, an educational hospital specializing in the care of patients with cancer. The postoperative/intensive care unit has 14 beds of recovery and short time intensive care. Nursing staff comprised 36 nurses; 13 were registered nurses, nineteen had a postgraduate degree in intensive care, and the remaining four were specialists in oncology, anesthesia, or midwifery.
Data from 304 patients were collected in a 14-week period from November 2020 to February 2021. In Phase 1 (Plan) of the study, standard care was registered by MetaVision for 3 weeks without the nurses’ knowledge about the study. The results of pain assessments, average was 1.86 per patient and average number of documented discharged criteria was 0.78 per patient per stay, were discussed with the head of the section and section's professional nurse educator before Phase 2 (Do), when the intervention commenced. With the unit's and study's goal, documented pain assessments could be improved from 1.86 to minimum 2 per patient per stay (one on arrival and one before discharge). Documented discharge criterion before discharge could improve from 0.78 to 1 (Figure 2). In order to ensure the quality of the patient's stay in the Postoperative Department in the Norwegian Radium Hospital, nurses are required to fill in an assessment form per patient (vital signs and pain) with scores less than 3 before discharge.
In Phase 2 (Do), week 4 and 6 of the study, the nursing staff was informed about the study through information at the section meeting and from an e-mail sent to all nursing staff, in addition there was a paper-reminder available bedside for 4 weeks (week 7-10 of the study). The educational intervention sessions occurred twice in a 2-week period and lasted 45 minutes each. The content of the sessions was knowledge about postoperative pain and how to use the assessment tools suitable for the current patient group in this unit. The sessions addressed practical views and guidance on how nurses registered in MetaVision the four validated pain assessment tools: the Numerical Rating Scale (NRS),
The use of BPS and CPOT as pain assessment tools were mostly used for the patients on arrival when they still were sedated from anesthesia and later with the NRS score when the patients were able to verbally self-report. The patients’ pain intensity defines that NRS score <3 was satisfactory/tolerable pain when the patients were able to breathe deeply. For the nurses that was adequate pain management. If the patients’ NRS score was >3 the patients should receive pain relief. One of the discharge criteria in postoperative unit was to ensure patients’ quality of pain management by NRS score ≤3. The educational sessions were filmed and held in an arena accessible for all staff in the unit to attend.
The study was approved as a quality improvement project by a privacy representative (PVO) (Ref.No: 20-23833) from Oslo University Hospital, the overarching institution of the Norwegian Radium Hospital. The need to require informed consent from patients and nurses was waived.
In Phase 3 (Study), the type of surgery, age, documented pain assessment, and opioid consumption were entered in Microsoft Excel and analyzed in SPSS Jamovi. Statistical process control was used to measure pain scores ≤3 (at rest) throughout the study and, later, average pain scores. Descriptive frequency analysis was performed in SPSS to calculate means, standard deviations, medians, minimums, and maximums. Correlation with Pearson's r-value and P < .05 at 95% confidence intervals were used to identify statistically significant differences in the nurses’ documentation of pain assessments. A data quality check in 10% of all data was performed by a research nurse, and less than 2% discrepancy was found.
In Phase 4 and 5 (Act); the results were presented for the section's leader and colleagues. The clinical quality of work was ensured by continuously documenting the pain assessments in the postoperative unit.
During Phase 3 (Study), the examination of the nursing documentation of pain assessments in MetaVision, when NRS score was mostly used by 94.1% (111) of the total 118 patients and unregistered pain assessment on arrival was 81.4% (96), revealed that pain assessments had been documented when patients were awake or could answer that they had pain. In some cases, additional pain relief was given without a documented pain assessment.
Characteristics of the Study Population
By age, the patients were more than 60 years old on average, and most were men by 55% (167) versus 45% (137) of women (Table 1). Plastic and orthopedic surgeries were 37.3% (44) preintervention and 33.3% (62) postintervention. Urological surgeries were 44.9% (53) preintervention and 36% (67) postintervention were the most common operations performed. Remaining gynecological surgeries were 15.3% (18) preintervention and 22.6% (42) postintervention, and abdominal surgeries were 1182.5% (3) preintervention versus 8.1% (15) postintervention. The mean patient's stay, approximately 3 hours, did not differ from pre- to post-intervention.
Table 1Clinical Demographics
Preintervention (N = 118)
Postintervention (N = 186)
Age in years, Mean (SD)
Plastic/orthopedic, including extirpation of all types of sarcomas
Patient's stay in the postoperative unit, Mean (SD) in minutes
Documented Pain Assessment and Patients’ Experiences
After intervention, specifically in Phase 3 (Study; Table 2), the nurses’ documentation of pain assessments per patient generally increased from 2.04 to 2.96 in mean. Use of the NRS with other pain assessment tools: BPS from 0.8% (1) to 1.1% (2), FLACC from zero to 1.1% (2), CPOT from 5.1% (6) to 25.8% (48). Documented pain assessment on arrival increased from 18.6% (22) to 75.8% (141), and the registered discharge criterion increased from 81.4% (96) to 91.4% (170). If patients could respond to verbal pain assessment in NRS scores ≤3, then they met the discharge criteria and were assumed to have received the standard adequate pain care required by the postoperative unit.
Table 2Documented Pain Assessment
Documented Pain Assessment Per Patient Per Stay in Postoperative and Intensive Care Unit
Preintervention N = 118 Patients N = 241 Pain Scores
Postintervention N = 186 Patients N = 550 Pain Scores
In Phase 4 (Act), the total average of opioid consumption increased from 3.34 to 4.79 in milligrams and in doses from 1.20 to 1.73 (Table 3). Opioid doses showed that the nurses’ documented use of pain measures increased from 28.2% (142) to 46.1% (321) after pain assessments. There was not significant change or improvement of the patients’ opiate doses, given without reassessment of their pain.
Table 3Documented Opioid Consumption
Documented Opioid Consumption Per Patient Per Stay in the Postoperative and Intensive Care Unit
Preintervention N = 118 Patients N = 142 Opioid Doses
Postintervention N = 186 Patients N = 321 Opioid Doses
Number of opioid doses, Mean (SD)
Number of Opioid doses, Median (min, max)
1.0 (0, 6)
1.0 (0, 9)
Opioid in milligrams, Mean (SD)
Opioid in milligrams, Median (min, max)
2.0 (0, 19.5)
3.0 (0, 32)
Frequency of opioid doses after pain assessment, N (%)
Number of opioid doses after pain assessment, Mean (SD)
All patients received general anesthesia or sedation. Prior to anesthesia, as a part of standard pain management, all patients received premedication paracetamol, dexamethasone, and long-acting opioid (Oxycodone Depot 10 mg). After surgery, the standard pain regimen regular paracetamol, intravenous or oral oxycodone, intravenous parecoxib, intravenous ketorolac, and a sedative or anxiolytic as needed prescribed in MetaVision by physicians. The opiate used in this study period was Oxycodone intravenous or oral.
Nurses’ Education and Work Experience
Despite there being 68 patients more in the postintervention, more pain assessments were documented. Documentation was greater than preintervention. Nursing staff specializing in intensive care, oncology, and midwifery had the most registered assessments from 53.4% (63) to 61.3% (114). For nurses with 0-10 years’ experience, the number of documented pain assessments from pre- to post-intervention had changed only slightly. However, nurses with more than 10 years of experience increased their volume from 17.8% (21) to 31.7% (59) which correlated with nurses’ education and positively correlated with nurses’ experience.
Analysis and Results Following Statistical Process Control (SPC)
Our analysis following SPC (Figure 2) revealed that information about the study preintervention in Phase 1 (during week 3 and 6), two educational sessions in Phase 2 (during weeks 7 and 8), and the paper reminder (from week 7-10) increased nurses’ pain assessments from a mean of two times per patient to three times. By partial correlation with documented pain assessments and the nurses’ education of pain assessment's tools revealed that nurses’ education did have a significant influence by Pearson’ r = 0.198 and P = .008.
Discharged criteria from this postoperative unit required that one NRS score ≤3 per patient per stay. The chart presents development of mean documented NRS per patient per stay per date. It shows that baseline process constitutes a mean of 1.9, and in Phase 3 delivered a mean of 2.65.
Figure 3 demonstrates that a shift in process was achieved; therefore an increasing higher performance of pain assessments were documented. However, improvement basically should have resulted in higher level performance and less variation. In our study we obtained higher performance, but not less variation (Figure 4). In our practice, it was not a goal to have the least possible variation. In all cases depending on patients’ clinical demographics, pain assessments should be made repeatedly. In other patients, it was correct to do it only once.
In Phase 3, the mean number of patients without documented pain assessment between each patient was 35.2 days, while in baseline (Phase 1) the mean number of days between was only 4.6 days. This corresponds to increased documented pain assessments and patients without documented pain assessments had become significantly rarer after the intervention.
The aim of our study was to investigate whether an educational intervention, in the form of teaching sessions could increase nurses’ documentation of postoperative pain assessments, alter patients’ opioid consumption, and ensure that patient have at least one documented numeric rating scale score ≤3 at rest before discharge. After the intervention, documented pain assessments increased significantly from a mean of two times to three times, opioid consumption increased as well, and the discharge criterion of one documented pain score ≤3 at rest per patient before leaving the unit was more often met.
Nurses’ Documented Pain Assessments per Patient
In Phase 1 (Plan), systematic pain assessments were investigated by recording nurses’ assessments of patients’ pain during their post-operative stays. In Phase 2 and 3 (Do and Study), documented pain assessments increased, as did the use of several pain assessment tools (Table 2) and patients without pain assessments decreased (Figure S1), which aligns with the findings of earlier surveys.
which demonstrated that staff education combined with the implementation of so-called “pain responsibility nurses” to remind colleagues to perform pain assessments, improved the focus on documenting and managing pain assessment. A systematic pain assessment is essential for quality patient care and associated with optimal pain treatment and better patient outcomes.
The use of NRS and CPOT when the patients were drowsy after anesthesia, especially increased, from 5.1% (6) to 25.8% (48) after the intervention (Table 2). That result aligns with past findings, indicating effectiveness of educational sessions and paper reminders as interventions.
But the nurses’ answers did not register how or when they did obtain their competence of pain assessment's tools. Therefore, there was no clear evidence of a direct link between the measures of nurses’ competence and the results. It requires further investigation.
In particular, nurses with more than 10 years’ experience increased their number of documented pain assessments after the intervention. Similar findings of increased pain assessments following intervention have been described by Liu et al.
in their randomized, open clinical trial involving a 3-month intervention with 2,278 patients in three surgery wards. A limitation in that study, however, was that the researchers did not include the patients whose stays were less than 48 hours. Relative to our study, the mean stay in the unit in that study was shorter (<24 hour).
Increased Opioid Consumption per Patient
In Phases 3 (Study) and 4 (Act), the improved number of nurses’ documented pain assessments increased the opioid consumption per patient (Figure S1 and Table 3), which could indicate that pain had been underestimated when the patient was still drowsy after surgery or hesitated to ask the nurse for help. Some patients, believing that pain after surgery was typical, may have endured their pain instead of reporting it.
The increased confirmation that patients were receiving satisfactory quality pain relief (NRS ≤3) in the postoperative phase, even if they were drowsy after surgery, suggested that the intervention based on systematic pain assessment and recording improved the documentation of postoperative pain.
In addition, it may have also increased the patients’ opioid consumption and their overall pain management. Similar findings of increased pain assessments and greater rates of prescribing analgesics were reported by Andersson and others.
Another reason that opioid consumption increased could be that if the target was an NRS score ≤3 at rest before discharge, reaching the desired goal could have been affected by administering more opioids, which lowered NRS scores.
the documented pain assessment (NRS score ≤3) assumed that patients were satisfied with their postoperative pain management. However, patients’ satisfaction with pain management may have been associated with their expectations, fears, former experiences, anxiety of pain, and the anticipated adverse effects of medications.
The target of our study's intervention was to ensure that patients had at least one documented NRS score ≤3 at rest before being discharged as a discharge criterion. Doing so was expected to indicate that the unit achieved the goal and upheld health personnel law regarding documentation.
In Phase 4 and 5, the evaluation phase, the results of the study (Table 2 and Figure 2) indicated that the unit had accomplished the goal with at least one documented pain assessment and one NRS score ≤3 at rest before discharge. In order (Phase 5) to be able to improve further, it is therefore necessary that the results are monitored continuously for use in the next PDSA cycle. If future studies follow Langley and Nolan's method, which builds on Deming's classic PDSA cycle, the intervention should be repeated at least once a year from the beginning of the cycle (ie, planning) and pursue new improvements.
A strength of our study was that the data were collected 3 weeks before the information about the study was announced. Therefore, the data reflected a normal workday for the nurses and their provision of standard care in the clinical setting. Another strength of the study was the total number of patients were 304.
Among the limitations, the 45-minutes educational sessions, delivered twice in two weeks, could not reach everyone on the nursing staff, even though the sessions were filmed and held in an arena accessible to everyone in the unit and reminders were e-mailed to the staff. Knowledge of the study and the paper-reminder might have influenced the results as well. To prevent having researchers in the field from affecting the results, the researchers were not involved in the care of the study's patients. Conducting research in your own workspace and with colleagues may have a Hawthorne effect: that dependent variable results from subjects’ awareness that they are participants under study.
A final limitation of the study was the period of data collection that was performed in one unit only. The number of patients and which surgeries were performed were planned based on the hospital's competence capacity.
Findings from Phase 5 in the study reveal that educational intervention sessions and reminders to perform basic systematic pain assessment and evaluate pain measures improved nurses’ documentation of postoperative pain management and discharge documentation. Beyond that, the longer the work experience of nurses in same unit, the more often they documented pain assessments. The findings underscore the importance of regularly ensuring the quality of patients’ treatment by systematically documenting nurses’ clinical tasks and the outcome of patients’ care.
Improving quality in pain assessments should take a long-term, continuous perspective so that clinical units can make new improvements at the beginning of next PDSA cycle. The reassessment and evaluation of pain after using pain measures especially needs further improvement.
We wish to especially thank the head of the section, Kirsti Juvik, for all the financial and emotional support given to the project, and the unit's professional nurse, Renate Ramfjord, who assisted in assuring the accuracy of data collection. Last, we additionally wish to thank to all the nursing staff members who collaborated during the study.