Postoperative pain assessment based on numeric ratings is not the same for patients and professionals: A cross-sectional study

doi:10.1016/j.ijnurstu.2011.07.009

International Journal of Nursing Studies

Volume 49, Issue 1, January 2012, Pages 65-71

https://doi.org/10.1016/j.ijnurstu.2011.07.009 Get rights and content

Abstract

Background

Numeric pain scores have become important in clinical practice to assess postoperative pain and to help develop guidelines for treating pain. Professionals need the patients’ pain scores to administer analgesic medication. However, do professionals interpret the pain scores in line with the actual perception of pain by the patients?

Objective

The study aim was to assess which Numerical Rating Scale (NRS) pain score was considered bearable on a Verbal Rating Scale (VRS) by patients and professionals.

Methods

This prospective study examined the relationship between the Numerical Rating Scale and a Verbal Rating Scale. The patients (n = 10,434) rated their pain the day after surgery on the 11-point NRS (0 = no pain and 10 = worst imaginable pain) and a VRS comprising five descriptors: “no pain”; “little pain”; “painful but bearable”; “considerable pain”; and “terrible pain”. The first three categories together (“no pain”, “little pain” and “painful but bearable”) were considered “bearable” and the last two categories (“considerable pain” and “terrible pain”) were deemed as “unbearable” pain. The professionals (n = 303) were asked to relate the numbers of the NRS to the words of the VRS.

Results

Most patients considered NRS 4–6 as “bearable” pain. Among professionals, anesthesiologists, Post Anaesthesia Care nurses, and ward nurses interpreted NRS scores in the same way as the patients. Only the Acute Pain Nurses interpreted the scores differently; they considered NRS of 5 and higher to be not bearable.

Conclusions

Some care providers and patients differ in their interpretation of the postoperative NRS scores. A risk of overtreatment might arise when health care providers rigidly follow guidelines that prescribe strong analgesics for pain scores above 3 or 4 without probing the patient's preference for pharmacological treatment.

Introduction

According to the American Pain Society guidelines (APS, 1995) for pain management, postoperative pain should be assessed regularly and documented carefully. The intensity of pain should be evaluated and recorded at intervals depending on the severity of pain and the clinical situation. Pain assessment and management is a significant part of nursing care and the pain is mostly assessed through verbal communication with the patient. The Numeric Rating Scale (NRS) is frequently used for this purpose: the patient is asked to score the pain on an 11 point scale, where 0 indicates no pain and 10 indicates the worst imaginable pain. The NRS is considered a valid and reliable pain assessment tool (Breivik et al., 2000, DeLoach et al., 1998, Good et al., 2001).

The patient's NRS score is a leading indicator in the postoperative pain treatment. Many guidelines for pain management recommend prescription of analgesics on the basis of the patients’ NRS pain score (American Pain Society, 1995, Gordon et al., 2005, veiligheidsprogramma, 2009). However, the NRS threshold for prescribing analgesics varies: some guidelines for acute and cancer pain chose an NRS cut-off >4 (American Pain Society, 1995, Gordon et al., 2005) while at least in one other, also for acute and cancer pain, an NRS cut-off >3 is the criterion for administering analgesics (VMS, 2009). Furthermore, in clinical practice not all patients with an NRS pain score above the treatment threshold are willing to accept the analgesic treatment offered mostly because they still consider the pain as “bearable”. This suggests that professionals and patients might perceive the necessity for pain treatment differently. If so, health care providers who strictly follow current guidelines could be at risk of overtreating some patients.

The aim of the study was to investigate how postoperative NRS pain scores of the patients relate to the presence of “bearable” versus “unbearable” pain. In a prospective study, the postoperative NRS pain scores were compared with the same patients’ adjectival descriptions of pain on a Verbal Rating Scale (VRS). The agreement between patients and professionals on the relationship between the NRS and VRS was then studied on the basis of comparisons between the two scales. We hypothesized that patients and professionals might differ in their interpretation of NRS scores.

Section snippets

Study design

We describe a cross-sectional study of a large sample of patients admitted for elective surgery. The current study was part of a large cluster-randomized study, implementing a prediction rule for improving the treatment of postoperative nausea and vomiting. In this study, 23,000 in- and out-patients participated. The study was approved by the institutional Ethics Committee of the University Medical Centre in Utrecht. It was not necessary to obtain informed consent from the patients because pain

Patients

The demographic and perioperative data are presented in Table 1. Data from 10,576 surgical inpatients were eligible for the current study; the other 12,424 patients underwent ambulatory surgery or did not meet the inclusion criteria. An NRS and VRS pain score pair was obtained 24 h after surgery from 10,434 patients. Data on one or both scales were incomplete for 142 patients, mainly because they were too sick to determine the pain score; failed to understand; were confused; or were

Discussion

The present study distinguishes ‘bearable’ from ‘unbearable’ postoperative pain and analyzes the relationship between NRS and VRS scores as assessed by postoperative patients and professionals. We found that most patients (65%) with NRS 4–6 considered their pain bearable. Among the professionals, the anesthesiologists, PACU and ward nurses interpreted the NRS scores in the same way as the patients. Only the Acute Pain Nurses interpreted the scores differently.

In previous studies, different

Conclusions

By combining data from a large sample of surgical patients with a national survey of health care workers, a lack of agreement is found between the patients and the Acute Pain Nurses on what constitutes ‘bearable’ pain in relation to the reported NRS scores. The Acute Pain Nurses tended to overestimate the severity of pain when the patients reported intermediate NRS scores, whereas most patients considered NRS 4–6 to be ‘bearable’ pain. These findings suggest a potential risk of overtreatment,

References (28)

J.N. Cashman et al.
Respiratory and haemodynamic effects of acute postoperative pain management: evidence from published data
British Journal of Anaesthesia
(2004)
S.J. Dolin et al.
Effectiveness of acute postoperative pain management: I. Evidence from published data
British Journal of Anaesthesia
(2002)
L. Gagliese et al.
The measurement of postoperative pain: a comparison of intensity scales in younger and older surgical patients
Pain
(2005)
D.D. McDonald et al.
Communicating pain and pain management needs after surgery
Applied Nursing Research
(2000)
T.R. Mendoza et al.
Lessons learned from a multiple-dose postoperative analgesic trail
Pain
(2004)
S. Taylor et al.
Has the pendulum swung too far in postoperative pain control?
American Journal of Surgery
(2003)
S. Taylor et al.
Postoperative day one: a high risk period for respiratory events
American Journal of Surgery
(2005)
C.H. Wilder-Smith et al.
Postoperative analgesia: pain by choice? The influence of patient attitudes and patient education
Pain
(1992)
M.L. Zalon
Nurses’ assessment of postoperative patients’ pain
Pain
(1993)
D.C. Zelman et al.
Development of a metric for a day of manageable pain control: derivation of pain severity cut-points for low back pain and osteoarthritis
Pain
(2003)

American Pain Society

Quality improvement guidelines for the treatment of acute pain and cancer pain

JAMA

(1995)

J.L. Apfelbaum et al.

Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged

Anesthesia and Analgesia

(2003)

E.K. Breivik et al.

A comparison of pain rating scales by sampling from clinical trial data

Clinical Journal of Pain

(2000)

J.W. Chung et al.

Postoperative pain management: study of patients’ level of pain and satisfaction with health care providers’ responsiveness to their reports of pain

Nursing and Health Sciences

(2003)

Cited by (88)

Pain and Satisfaction Perceptions of Ultrasound-Guided Versus Conventional Peripheral Intravenous Catheterization: A Randomized Controlled Trial
2024, Pain Management Nursing
While many emergency department (ED) patients need peripheral vascular catheterization, diagnosis and treatment are often delayed by difficult intravenous access (DIVA).
This study of ED patients with DIVA was designed to evaluate ultrasound (US)-guided peripheral intravenous (IV) catheterization, compare it with conventional catheterization, and analyse patient pain and satisfaction regarding catheterization.
Randomized controlled clinical trial.
Adult patients treated in the ED who scored >3 on the Adult-Difficult Venous Catheterization scale were randomly assigned to either US-guided or conventional peripheral IV catheterization. Data were collected from April to December 2016. Study variables were catheter insertion success, number of catheterization attempts, time required to perform the procedure, catheter length and calibre, puncture site, complications, and catheter functioning. Pain and patient satisfaction were also analysed for each group and the full sample.
120 and 138 patients were recruited for the US-guided and conventional peripheral IV catheterization groups, respectively. For the US-guided compared to the conventional procedure, insertion success was greater (91.75% versus 89.9%; p=0.04), the mean (SD) number of attempts was lower (1.29 (0.59) versus 1.81 (1.28); p<0.001), mean (SD) satisfaction was greater (7.59 (2.04) versus 6.69 (2.28); p=0.03), and the mean (SD) required time in minutes was greater (7.89 (7.13) versus 5.1 (3.69); p=0.045). Mean (SD) pain was moderate in both groups (4.6 (2.75) versus 4.33 (2.91) (p=0.32). Logistic regression for the full sample indicated that more attempts and greater pain were both associated with reduced satisfaction, while use of higher-calibre catheters was associated with greater satisfaction.
US-guided compared to conventional peripheral IV catheterization in patients with DIVA was more successful, required fewer attempts, enabled use of longer and higher-calibre catheters, and led to greater patient satisfaction. Patients who underwent US-guided intravenous catheterization reported moderate pain, similar to that reported for the conventional procedure.
US-guided peripheral intravenous catheterization improves ED patient care, as it requires fewer catheterization attempts. It is especially recommended for patients with DIVA.
Determining the Effect of Telehealth Intervention for Lupus Patients on Pain, Happiness, and Life Activities: A Randomized Controlled Study
2024, Pain Management Nursing
This study aims to determine the effect of a telehealth intervention for SLE patients on pain, happiness, and life activities.
The study was conducted as a randomized controlled study. The sample of the study consisted of a total of 73 participants, including the experimental group (n = 37) and the control group (n = 36). Random number generation using Excel was used to determine how subjects were randomly assigned to treatment and control groups. Numerical Rating Scale, Oxford Happiness Scale Short Form, and Life Activities Scale were used to collect data. In addition to their routine treatments, participants in the experimental group received telehealth intervention once a week for 12 weeks, each intervention lasting 15 to 20 minutes. No application was made to the control group during the intervention. Scales were applied to both groups at the beginning of the study, in the 6th week, and in the 12th week.
Pain scores of the experimental group were lower at the 6th and 12th weeks compared to the beginning. While there was no difference in pain comparison between the groups at the 6th and 12th weeks, the pain score of the experimental group at the 12th week was significantly lower than the control group. It was determined that the happiness scale scores in the experimental group were higher at the 6th and 12th weeks compared to the beginning. At the end of the 12th week, the happiness score of the experimental group was higher than the control group. It was determined that the life activities scores in the experimental group were higher at the 6th and 12th weeks compared to the beginning.
It has been determined that telehealth application has a positive effect on the pain, happiness, and life activities of SLE participants. We suggest that future research should be conducted to improve the body image of SLE participants.
Surgery patients’ perspectives of their role in postoperative pain: A scoping review
2023, International Journal of Nursing Studies Advances
Post-operative pain is a major factor in surgical recovery. There is evidence that pain remains undermanaged. Complications related to the undermanagement of acute pain can increase length of stay and contribute to readmission and the development of chronic pain. It is well acknowledged that pain assessment is critical to pain management and that self-report of pain is the gold standard. As a result, patients play a central role in their own pain management. A preliminary review of the literature failed to provide a clear or consistent description of this key patient role.
A scoping review was conducted with the objective of reviewing literature that described adult patients’ perspectives or highlighted the adult patient's role in post-operative pain management, including assessment. Understanding patients’ attitudes toward their roles in pain management through a scoping review of the current literature is critical for informing research and improvements in post-operative pain management.
Scoping review.
The databases searched for the review included CINAHL, MEDLINE, PubMed, and SCOPUS (ending May 2022). Thematic analysis, using the methodology of Arksey and O'Malley, was applied to the records identified
Of the 106 abstracts initially identified, 26 papers were included in the final analysis. Two major themes identified through thematic analysis were attitudes toward pain and pain management, with the subthemes of patient expectations and beliefs and desire to treat; and care and communication, with the subthemes of pain assessment and education.
This paper provides one of the first known comprehensive scoping reviews of surgical patients’ perspectives of their role in pain management, including assessment, and offers an important global awareness of this patient role. The findings suggest that improved understanding of patients’ perspectives of their roles in pain assessment and treatment is critical to improving post-operative pain management. Engaging patients as partners in their care can facilitate enhanced communication and improving congruence in pain assessment and treatment decisions. The complex nature of patients’ beliefs, expectations, and subjective experiences of pain present challenges for health care practitioners. These challenges can be met with enhanced education for patients, respect for patients’ beliefs and expectations, and the provision of dignified care.
Patient satisfaction in ambulatory anesthesia assessed by the Heidelberg Peri-anaesthetic Questionnaire: a cross-sectional study
2023, Brazilian Journal of Anesthesiology (English Edition)
Service quality in anesthesiology has been frequently measured by morbidity and mortality. This measure increasingly considers patient satisfaction, which is the result of care from the client's perspective. Therefore, anesthesiologists must be able to build relationships with patients, provide understandable information and involve them in decisions about their anesthesia. This study aimed to evaluate the peri-anesthetic care provided by the anesthesia service in an ambulatory surgery unit using the Heidelberg Peri-anaesthetic Questionnaire.
This cross-sectional study used the Heidelberg Peri-anaesthetic Questionnaire to evaluate 1211 patients undergoing ambulatory surgery. We selected questions that showed a greater degree of dissatisfaction and correlated them with patient characterization data (age, sex, education, and ASA physical status), anesthesia data (type, time, and prior experience), and surgical specialty.
Questions in which patients tended to show dissatisfaction involved fear of anesthesia and surgery, feeling cold, the urgent need to urinate, pain at the surgical site, and the team's level of concern and speed of response in relieving the patient's pain.
The Heidelberg Peri-anaesthetic Questionnaire proved to be a useful tool in identifying points of dissatisfaction, mainly fear of anesthesia and surgery, feeling cold, the urgent need to urinate, pain at the surgical site, and the team's level of concern and speed of response in relieving the patient's pain in the population studied. These were correlated with patient, anesthesia, and surgical variables. This allows the establishment of priorities at the different points of care, with the ultimate goal of improving patient satisfaction regarding anesthesia care.
Identifying Patients Vulnerable to Inadequate Pain Resolution After Cardiac Surgery
2022, Seminars in Thoracic and Cardiovascular Surgery
Acute postoperative pain (APOP) is often evaluated through granular parameters, though monitoring postoperative pain using trends may better describe pain state. We investigated acute postoperative pain trajectories in cardiac surgical patients to identify subpopulations of pain resolution and elucidate predictors of problematic pain courses. We examined retrospective data from 2810 cardiac surgical patients at a single center. The k-means algorithm for longitudinal data was used to generate clusters of pain trajectories over the first 5 postoperative days. Patient characteristics were examined for association with cluster membership using ordinal and multinomial logistic regression. We identified 3 subgroups of pain resolution after cardiac surgery: 37.7% with good resolution, 44.2% with moderate resolution, and 18.2% exhibiting poor resolution. Type I diabetes (2.04 [1.00–4.16], p = 0.05), preoperative opioid use (1.65 [1.23–2.22], p = 0.001), and illicit drug use (1.89 [1.26–2.83], p = 0.002) elevated risk of membership into worse pain trajectory clusters. Female gender (1.72 [1.30–2.27], p < 0.001), depression (1.60 [1.03–2.50], p = 0.04) and chronic pain (3.28 [1.79–5.99], p < 0.001) increased risk of membership in the worst pain resolution cluster. This study defined 3 APOP resolution subgroups based on pain score trend after cardiac surgery and identified factors that predisposed patients to worse resolution. Patients with moderate or poor pain trajectory consumed more opioids and received them for longer before discharge. Future studies are warranted to determine if altering postoperative pain monitoring and management improve postoperative course of patients at risk of moderate or poor pain resolution.
Clinical Interpretation of Self-Reported Pain Scores in Children with Acute Pain
2022, Journal of Pediatrics
To identify self-reported pain scores that best represent categories of no pain, mild, moderate, and severe pain in children, and a pain score that accurately represents a child’s perceived need for medication, that is, a minimum pain score at which a child would want an analgesic.
Prospective cross-sectional cohort study of children aged 6-17 years presenting to a pediatric emergency department with painful and nonpainful conditions. Pain was measured using the 10-point Verbal Numerical Rating Scale. Receiver operating characteristic –based methodology was used to determine pain scores that best differentiated no pain from mild pain, mild pain from moderate pain, and moderate pain from severe pain. Descriptive statistics were used to determine the perceived need for medication.
We analyzed data from 548 children (51.3% female, 61.9% with a painful condition). The scores that best represent categories of pain intensity are as follows: 0-1 for no pain; 2-5 for mild pain; 6-7 for moderate pain; and 8-10 for severe pain. The area under the curve for the cut points differentiating each category ranged from 0.76 to 0.88. The median pain score representing the perceived need for medication was 6 (IQR, 4-7; range, 0-10).
We identified population-level self-reported pain scores in children associated with categories of pain intensity that differ from scores conventionally used. Implementing our findings may provide a more accurate representation of the clinical meaning of pain scores and reduce selection bias in research. Our findings do not support the use of pain scores in isolation for clinical decision making or the use of a pain score threshold to represent a child’s perceived need for medication.

View all citing articles on Scopus

View full text

Postoperative pain assessment based on numeric ratings is not the same for patients and professionals: A cross-sectional study

Abstract

Background

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Study design

Patients

Discussion

Conclusions

British Journal of Anaesthesia

British Journal of Anaesthesia

Pain

Applied Nursing Research

Pain

American Journal of Surgery

American Journal of Surgery

Pain

Pain

Pain

Quality improvement guidelines for the treatment of acute pain and cancer pain

JAMA

Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged

Anesthesia and Analgesia

A comparison of pain rating scales by sampling from clinical trial data

Clinical Journal of Pain

Postoperative pain management: study of patients’ level of pain and satisfaction with health care providers’ responsiveness to their reports of pain

Nursing and Health Sciences