Вы находитесь на странице: 1из 7

Original Article

Postoperative Pain:
Nurses’ Knowledge and
Patients’ Experiences
--- Lavonia Francis, DNP, RN, NEA-BC,*
and Joyce J. Fitzpatrick, PhD, RN, FAAN†

The aim of this study was to determine nurses’ knowledge and
attitudes regarding postoperative pain and identify postoperative pa-
tients’ pain intensity experiences. The assessment and management of
acute postoperative pain is important in the care of postoperative
surgical patients. Inadequate relief of postoperative pain can con-
tribute to postoperative complications such as atelectasis, deep vein
thrombosis, and delayed wound healing. A pilot study with an
exploratory design was conducted at a large teaching hospital in the
eastern United States. The convenience samples included 31 nurses
from the gastrointestinal and urologic surgical units and 14 first- and
second-day adult postoperative open and laparoscopic gastrointesti-
nal and urologic patients who received patient-controlled analgesia
(PCA). The Knowledge and Attitudes Survey Regarding Pain was
used to measure nurses’ knowledge about pain management. The
Short-Form McGill Pain Questionnaire (SF-MPQ) was used to measure
patients’ pain intensity. The nurses’ mean score on the Knowledge and
Attitudes Survey Regarding Pain was 69.3%. Patients experienced
moderate pain, as indicated by the score on the SF-MPQ. There is
a need to increase nurses’ knowledge of pain management.
From the *Mount Sinai Medical Ó 2013 by the American Society for Pain Management Nursing
Center, New York, New York; †Frances
Payne Bolton School of Nursing, Case
Western Reserve University, The assessment and management of acute postoperative pain is an important as-
Cleveland, Ohio.
pect in the care of surgical patients. Pain management is a vital component in the
Address correspondence to Lavonia recovery of postoperative patients. Pain can diminish a patient’s ability to partic-
Francis, DNP, RN, NEA-BC, Senior ipate in postoperative interventions such as coughing, deep breathing, and am-
Director of Nursing, Mount Sinai bulating. These interventions are key elements in preventing postoperative
Medical Center, One Gustave Levy complications. Challenges such as lack of patient assessment in managing pain
Place, New York, NY 10029. E-mail:
and lack of appropriate use of analgesics have been reported (Gunningberg &
Idvall, 2007; Idvall & Berg, 2008; White & Kehlet, 2010). Pain management is
Received June 25, 2011; multifaceted and requires a multidisciplinary approach in improving patient
Revised May 2, 2012; outcomes.
Accepted May 24, 2012.

Ó 2013 by the American Society for BACKGROUND
Pain Management Nursing
http://dx.doi.org/10.1016/ Owing to the subjective nature of pain, assessment and management of pain can
j.pmn.2012.05.002 be a complex process. Timing, route, and appropriate use of analgesics need to

Pain Management Nursing, Vol 14, No 4 (December), 2013: pp 351-357

352 Francis and Fitzpatrick

be considered in the management of pain. Despite ad- The findings revealed that the mean score for four ques-
vances in pain management, such as patient-controlled tion items in general surgery and five items in thoracic
analgesia (PCA) and multimodal analgesia, patients surgery was >4.5, which indicated high quality of pa-
continue to experience moderate to severe pain tient care. Patients in general surgery experienced
(Bedard, Purden, Sauve-Larose, Certosini, & Schein, more pain than patients in thoracic surgery. Patients in
2006; Brown, Constance, Bedard, & Pruden, 2011; general surgery assessed their worst pain to be signifi-
Niemi-Murola, Poybia, Onkinen, Rhen, Makela, & cantly higher than the nurses did. The mean score for
Niemi, 2007). The role of the nurse is pivotal in the as- the patients’ worst pain during the past 24 hours was
sessment and management of postoperative pain. 5.7 and the nurses’ score was 4.5 on a scale range of
Nurses need to understand the pathophysiology of 0-10. A significant difference was found in both services
pain and recognize that pain management is vital in in the assessments of worst pain during the past 24
the recovery of postoperative patients. Pain assess- hours between patients, nurses, and documentation in
ment and reassessment are components of the nurse’s the patient record. Pain intensity assessment was docu-
role that are key in pain management. Therefore, the mented significantly more often in general surgery
purpose of this pilot study was to determine nurses’ (41%) than in thoracic surgery (6.7%).
knowledge and attitudes regarding postoperative Idvall, Berg, Unosson and Brudin (2005) investi-
pain and identify patients’ level of pain intensity. gated the differences between nurse and patient as-
sessments of postoperative pain management in two
hospitals with the use of the Strategic and Clinical
PAIN MANAGEMENT AND Quality Indicators in Postoperative Pain Management
ASSESSMENT questionnaire. The findings revealed that the correla-
The most reliable indicator of pain is the patient’s self- tion between patient and nurse ratings for both hospi-
report (Institute for Clinical Systems Improvement, tals regarding worst pain during the past 24 hours was
2008). Patients communicate pain verbally and statistically significant (r ¼ 0.57-0.59). Patients rated
through body and facial expressions. Therefore, pa- their worst pain during the past 24 hours higher than
tient observation and the use of pain assessment tools, the nurses’ rating (p < .05). Idvall and Berg (2008)
such as the visual analog scale (VAS) need to be used in also used the Strategic and Clinical Quality Indicators
the assessment of postoperative pain. Nurses’ and pa- in Postoperative Pain Management questionnaire in
tients’ assessment of pain has been documented their study of how orthopedic patients assessed the
(Gunningberg & Idvall, 2007; Sloman, Rosen, Rom, & quality of care they received. One of the question items
Shin, 2005). Sloman et al. (2005) studied nurses’ rat- rated highest was that pain relief was addressed
ings of pain intensity and suffering compared with pa- promptly when requested. The item rated lowest
tients’ own ratings of these variables in adult surgical was the regular use of a pain assessment instrument.
patients. Patients completed the Short-Form McGill Eid and Bucknall’s (2008) retrospective audit of
Pain Questionnaire (SF-MPQ), VAS, and demographic patients’ medical records demonstrated that nurses’
questionnaire. Nurses assessed their assigned patients documentation of pain assessment and management
and then completed the same questionnaires. The find- was insufficient in their study of postoperative pain
ings indicated that nurses significantly underrated pain management in older patients (n ¼ 43) with hip frac-
compared with patients on pain sensation (t ¼ 3.131; tures. The study findings indicated that there was no
p ¼ .002), pain affect (t ¼ 4.410; p ¼ .0001), present documentation of pain intensity rating using the VAS
pain intensity at rest (t ¼ 3.498; p # .001), present in 77% of the reviewed medical records and no docu-
pain intensity on movement (t ¼ 6.278; p # .0001), mentation of pain assessment in 65% of the records.
overall pain intensity (t ¼ 2.235; p ¼ .028), and patient Neither nonpharmacologic intervention nor pain man-
suffering due to pain (t ¼ 3.774; p # .0001). There agement education was documented.
were no statistically significant effects found for demo- Lin and Wang (2005) examined the effects of post-
graphic or cultural data. operative nursing intervention for pain related to ab-
Gunningberg and Idvall (2007) used a descriptive dominal surgical patients’ preoperative anxiety, pain
and comparative design to study the quality of postoper- attitude, and postoperative pain. A questionnaire and
ative pain management. Paired patient and nurse assess- the Brief Pain Inventory were used. The findings re-
ments of patients’ pain management were conducted in vealed that there was a statistically significant differ-
general and thoracic surgery services. The Strategic and ence (F ¼ 174.03; p < .001) in the mean anxiety
Clinical Quality Indicators in Postoperative Pain Man- scores after the preoperative nursing intervention for
agement questionnaire was completed by patients and pain between the experimental group and the control
nurses. Audit of patient records was also completed. group. Additionally, there was a statistically significant
Postoperative Pain and Patients’ Experiences 353

difference (F ¼ 260.58; p < .001) in pain attitude and negatively related to perceived barriers to pain man-
pain scores between the two groups. The researchers agement (r ¼ 0.12; p < .01).
suggested that preoperative nursing intervention for
pain has positive effects on preoperative pain anxiety
and attitude and pain perception.
Design and Setting
A descriptive exploratory design was used. The pilot
study was conducted at a large full-service teaching
MANAGEMENT hospital in the eastern United States.
Matthews and Malcolm (2007) surveyed two groups of
nurses with the Nurses’ Knowledge and Attitudes Sur- Samples
vey Regarding Pain. The nurses in group 1 worked at Thirty-one registered nurses from the gastrointestinal
an orthopedic center and completed a knowledge and urologic surgical units participated. Newly hired
and competency program in pain management. Group nurses with <3 months’ experience on their unit
2 nurses attended a pain conference but did not com- were excluded. These nurses were in the orientation
plete the knowledge and competency program. The phase and may not have completed the educational
nurses in group 2 worked in a variety of clinical areas. component for pain assessment and management. The
The overall mean score on the survey for both nurses were not paired with the patient participants.
groups was 73.8%. The findings showed that there Fourteen first- and second-day adult postoperative
was no significant difference in the total of correct re- open and laparoscopic gastrointestinal and urologic
sponses between the two groups. However, there was procedure patients receiving PCA participated in the
a severe deficit in knowledge related to questions re- study. The sample consisted of patients who spoke
garding nonpharmacologic interventions and opioid and understood English. Cognitively impaired patients
use in chronic pain conditions. Another finding were excluded from the study, as were patients with
was that group 1 had a higher correct response rate a history of past or active substance abuse or long-
(p ¼ .001) than group 2 for the scenario questions. term opioid treatment.
Wilson (2007) studied nurses’ knowledge of pain
management among 35 oncology nurse specialists and Measures
37 general nurses with the use of a revised version of Nurses’ Knowledge of Pain Management. The
the Knowledge and Attitudes Survey Regarding Pain. Knowledge and Attitudes Survey Regarding Pain devel-
Wilson reported that the oncology nurse specialists’ oped by Ferrell and McCaffery (2005) was used. This
mean score (79.42%) was higher than the mean score instrument consists of 21 true/false and 17 multiple
(64.86%) of the general nurses; however, the nurse choice questions. The last two items of the multiple
specialists’ knowledge scores were not consistent choice questions have two parts. Ferrell and McCaffery
with their years of experience. Abdalrahim, Majala, recommended not distinguishing items as measuring
Stomberg and Bergdam (2010) explored nurses’ either knowledge or attitude, because many of the
knowledge and attitudes toward pain on surgical units items measure both knowledge and attitude, but rather
before and after implementation of a postoperative analyzing data in terms of the percentage of correct
management program. A 21-item questionnaire was scores as well as analyzing individual items. For the
used and patient records audited. The overall score present study, items 1-36 were each assigned 1 point
for correct answers on the questionnaire during the and items 37 and 38 were each assigned 2 points for
preintervention phase was 45.7%. The score in- scoring. The data were analyzed by percentage of cor-
creased to 75% after implementation of the program. rect scores.
Improvement was also noted in documentation of The Knowledge and Attitudes Survey Regarding
pain management in the patients’ records after imple- Pain has been tested for evidence of validity and reli-
mentation of the postoperative pain management ability. Content validity has been established by review
program. of pain experts (Ferrell & McCaffery, 2005). The con-
Wang and Tsai (2010) studied nurses’ knowledge tent is based on standards of pain management devel-
and barriers regarding pain management among 370 oped by the American Pain Society, the World Health
intensive care unit nurses in 16 hospitals. The findings Organization, and the Agency for Health Care Policy
indicated that the overall average of correct response and Research. Construct validity has been established
rate for the Nurses’ Knowledge and Attitudes Survey by comparing scores of nurses at various levels of ex-
was 53.4%. The researchers also reported that nurses’ pertise. Test-retest reliability has been established by
knowledge of pain management was significantly and repeated testing in a continuing education class of staff
354 Francis and Fitzpatrick

nurses (r > 0.80). Internal consistency reliability was attending unit staff meetings. The investigator de-
established with items reflecting both knowledge and scribed the study and explained the purpose of the
attitude (r > 0.70) (Ferrell & McCaffery). study. Research packets containing a cover letter, de-
Postoperative Pain Intensity. Patients’ pain inten- mographic questionnaire, the Knowledge and Atti-
sity was measured by three scores on the SF-MPQ. tudes Survey Regarding Pain, and return envelope
The SF-MPQ provides quantitative measures of clinical were distributed to the nurse participants.
pain (Melzack, 1975). The SF-MPQ was developed
from the long-form McGill Pain Questionnaire
(Melzack, 1987). The SF-MPQ consists of three sec-
tions. The first section of the questionnaire consists Sample
of 15 adjectives that describe sensory and affective di- There were two samples for this pilot study, a conve-
mensions of pain. Eleven items represent sensory de- nience sample of 31 nurse participants and a conve-
scriptors of pain and four items represent affective nience sample of 14 patient participants from three
descriptors of pain. Each descriptor has four responses surgical units at a large teaching hospital in the eastern
as follows: 0 ¼ none; 1 ¼ mild; 2 ¼ moderate; and 3 ¼ United States. Sixty nurse questionnaires were distrib-
severe. Subjects respond by rating each descriptor of uted; 31 (51.6%) nurse participants returned com-
their pain ‘‘now.’’ Three pain scores are derived from pleted questionnaires. Seventy-two patients were
the sum of the intensity values of the descriptors cho- approached; 14 patients agreed to participate in the
sen for sensory, affective, and combined scores of the study, for a response rate of 19%. Patients who were
patient’s chosen descriptors. The range of possible not willing to participate were either not interested
scores for each descriptor is 0-3 and range of possible or requested that the investigator come back on an-
combined scores is from 0 to 45. The higher the score, other day. For logistical reasons it was not possible to
the greater the intensity of pain. contact them on another day. The nurses were not
The second section of the SF-MPQ consists of paired with the patient participants.
a VAS. The VAS scale ranges from no pain to worst pos-
sible pain. Subjects are shown the scale and are in- Characteristics of Nurse Participants
structed to place a mark on the scale indicating their The nurses’ ages ranged from 22 to 62 years. The mean
pain level. The third section of the SF-MPQ consists age for the nurse participants was 36 years (SD 12.1).
of the present pain intensity (PPI) index. The ratings Twenty five (80.6%) were female and 6 (19.4%) male.
for the PPI are 0 ¼ no pain; 1 ¼ mild pain; 2 ¼ discom- The educational characteristics of the nurse par-
forting pain; 3 ¼ distressing pain; 4 ¼ horrible pain; ticipants included education level and pain manage-
and 5 ¼ excruciating pain. A separate score is reported ment education. Twenty-eight nurse participants
for each section. The higher the score, the greater the (90.3%) received a Bachelor of Science in Nursing
intensity of pain. (BSN) as their basic nursing preparation and one
The SF-MPQ has been tested for evidence of reliabil- (3.2%) received an Associate degree. Two participants
ity and validity. A study was conducted to compare the (6.5%) received a Master of Science in Nursing. Eleven
long form and short form of the McGill Pain Question- of the nurse participants (44%) had not attended a pain
naire (Melzack, 1987). The first section of the SF-MPQ management education session outside the study facil-
was compared to the long form with 90 patients. The ity. Seven (28%) had attended a half-day pain manage-
study groups included patients in postsurgical and ob- ment educational session and seven (28%) had
stetrical units and patients with musculoskeletal pain attended a full-day pain educational session.
in a physiotherapy department. The findings of the study The work-related characteristics examined were
revealed that the sensory, affective, and total scores from years of nursing experience, years working on current
the short and long forms of the McGill Pain Question- unit, and years of other surgical experience. Years of
naire were significantly correlated. Correlation coeffi- nursing experience ranged from 1 to 40 years with
cients were r ¼ 0.88 (p ¼ .001) (Melzack, 1987). a mean of 7.9 years (SD 9.1). Fourteen nurse partici-
pants (48.3%) had <5 years of nursing experience, 8
Procedure (27.6%) had 5-10 years, 3 (10.3%) had 11-15 years, 2
Institutional Review Board approval was obtained be- (6.9%) had 16-20 years, and 2 (6.9%) had >20 years
fore data collection. Patients were approached on the of experience.
first and second postoperative days. The researcher in- Years of other surgical experience ranged from
terviewed the patients using the SF-MPQ and demo- 1 to 28 years with a mean of 8.1 years (SD 8.2). Six
graphic questionnaire after obtaining signed consent. nurse participants (20.7%) had surgical experience
Face-to-face recruitment of nurses was done by of 1-5 years; 2 (6.9%) had 6 to 10 years; 1 (3.4%) had
Postoperative Pain and Patients’ Experiences 355

11 to 15 years, 1 (3.4%) had 16-20 years, and 1 (3.4%)

had >20 years of other surgical experience. Sample TABLE 2.
characteristics of the nurses are included in Table 1. Nurse Participants (n ¼ 31): Knowledge and
The mean score on the Knowledge and Attitudes Attitudes Survey Regarding Pain
Survey Regarding Pain was 69.3%. These results are in-
Mean (%) SD
cluded in Table 2. There were no significant differ-
ences found between the mean scores and the Overall Score 69.3 4.9
demographic variables of the nurse participants. Score by age (y)
<40 69.1 4.1
40 to <60 73.0 6.6
Characteristics of Patient Participants $60 70.5 2.1
The patients’ ages ranged from 28 to 71 years. The Scores by educational level
mean age was 51 years (SD 12.9). Six (42.9%) were fe- Bachelors 69.1 3.9
male and 8 (57.1%) male. Eleven (78.6%) patients were Masters 69.0 15.6
white, 2 (14.3%) were black, and 1 (7.1%) was of an-
other racial background. Twelve patients’ birth place
was the United States (85.7%), and 2 (14.3%) were were interviewed on the first postoperative day and
born outside of the United States. three (21.4%) were interviewed on the second postop-
Four of the patient participants (28.6%) com- erative day. Nine first-day postoperative patients
pleted high school, 3 (21.4%) received a bachelor de- (64.3%) had open procedures and two (14.3%) had lap-
gree, 3 (21.4%) received a master degree, and 4 aroscopic procedures. Two second-day postoperative
(28.6%) had other educational background. Sample patients (14.3%) had open procedures and one
characteristics of the patients are included in Table 3. (7.1%) had a laparoscopic procedure. These results
Fourteen postoperative day 1 and day 2 gastroin- are included in Table 4.
testinal and urologic patients participated in the study. All of the patient participants received PCA. Thir-
The operative procedures were as follows: one (7.1%) teen patients (92.9%) received peripheral PCA and one
open urologic procedure; one (7.1%) laparoscopic uro- (7.1%) received epidural PCA. Six patients (42.8%) re-
logic procedure, ten (71.4%) open gastrointestinal pro- ceived fentanyl PCA and eight (57.1%) received mor-
cedures; and two (14.3%) laparoscopic gastrointestinal phine PCA. One (7.1%) patient received epidural
procedures. Eleven of the patient participants (78.6%) fentanyl PCA. These results are included in Table 4.
The SF-MPQ was used to measure the postopera-
tive patients’ pain intensity. The SF-MPQ consists of
TABLE 1. three sections. A separate score was calculated for
each section. The results were analyzed as follows:
Characteristics of Nurse Participants (n ¼ 31)
n %

Age (y) TABLE 3.

22-35 15 53.5 Characteristics of Patient Participants (n ¼ 14)
36-55 10 35.7
56-62 3 10.7 n %
Female 25 80.6 Age (y)
Male 6 19.4 28-40 4 28.6
Education 41-60 6 42.8
MSN 2 6.5 >60 4 28.6
BSN 28 90.3 Sex
Associate 1 3.2 Female 6 42.9
Pain management education Male 8 57.1
None 11 44 Race
Half day 7 28 White 11 78.6
Full day 7 28 Black 2 14.3
Nursing experience (y) Other 1 7.1
<5 14 48.3 Education
5-10 8 27.6 High school diploma 4 28.6
11-15 3 10.3 Bachelor degree 3 21.4
16-20 2 6.9 Master degree 3 21.4
>20 2 6.9 Other 4 28.6
356 Francis and Fitzpatrick

perception of pain management and insufficient docu-

TABLE 4. mentation of pain assessment have been reported (Eid
Clinical Characteristics of Patient Participants & Bucknall, 2008; Gunningberg & Idvall, 2007; Idvall &
(n ¼ 14) Berg, 2008; Idvall et al., 2005; Sloman et al., 2005). In-
tervention processes for improving postoperative pain
n %
management also have been documented (Abdalrahim
Procedure et al., 2010; Lin & Wang, 2005). Based on the reported
Urologic findings, there is a need to improve pain management.
Open 1 7.1 The mean score on the Knowledge and Attitudes
Laparoscopic 1 7.1
Survey Regarding Pain for the present pilot study was
Open 10 71.4 69.3%. Similar mean score findings, ranging from
Laparoscopic 2 14.3 45.7% to 73.8%, have been reported (Abdalrahim
Procedures by postoperative day et al. 2010; Matthews & Malcolm, 2007; Wang & Tsai,
Day 1 11 78.6 2010; Wilson, 2007). The mean score for the knowl-
Day 2 3 21.4
edge questions in the present study was lower than
Open procedures
Postoperative day 1 9 64.3 the mean score for the attitude questions. All of the
Postoperative day 2 2 14.3 nurse participants correctly answered item no. 30
Laparoscopic procedures (the most accurate judge of the intensity of the patient’s
Postoperative day 1 2 14.3 pain is the patient). This response indicates that the
Postoperative day 2 1 7.1
nurse participants in this pilot study understand the
PCA method
Peripheral 13 92.9 concept that pain is subjective and that the patient’s
Epidural 1 7.1 pain is whatever the patient indicates. There were no
Analgesic significant differences in the mean scores between
Fentanyl the three units nor significant differences between
Peripheral PCA 5 35.7
the mean scores and the nurses’ demographic variables.
Epidural 1 7.1
Morphine The sample size of this pilot study was small and limited
Peripheral PCA 8 57.1 to specific clinical services. The findings can not be
generalized to other units at the study facility.
The results of the SF-MPQ indicated that the pa-
overall scores; scores by unit, postoperative day, proce- tient participants experienced moderate pain intensity
dures, and analgesics; and scores by age, sex, race, and based on the mean score of the descriptors of pain and
educational level. VAS sections. This finding was consistent with other re-
The mean scores for each section of the SF-MPQ ported findings regarding patients’ pain experiences
were as follows: descriptors of pain (section 1), 13.9 (Bedard et al., 2006; Brown et al., 2011; Neimi-
(SD 7.9); VAS (section 2), 4.6 (SD 1.9); and present Murola et al., 2007). Pain management is an important
pain intensity index (section 3), 2.2 (SD 1.3). These re- aspect of care for postoperative patients. Adequate
sults are included in Table 5. There were no significant pain relief allows patients to participate in activities
differences found between the mean scores and demo- that can prevent postoperative complications. Effec-
graphic variables of the patient participants. tive pain management requires the intervention of mul-
tiple disciplines.
Study Limitations
Pain assessment and nurses’ knowledge regarding pain The limitations of this pilot study were the small sample
management have been studied. Nurse and patient size and the limited surgical services. There were only
two patients from the urologic surgical service. Thus,
all of the patient variables could not be compared
with the patients on the urologic service. The results
Short-Form McGill Pain Questionnaire: Patient
of the study can not be generalized in similar settings.
Participants’ Scores (n ¼ 14)
Mean SD Implications for Practice
Pain management is an important aspect in the recov-
Descriptors of pain 13.9 7.9 ery of postoperative patients. Nurses have a vital role
Visual analog scale 4.6 1.9
in promoting positive patient outcomes. Therefore,
Present pain intensity index 2.2 1.3
nurses need to be knowledgeable about pain
Postoperative Pain and Patients’ Experiences 357

assessment and management. The nurses’ mean score surgical services with paired nurse patient partici-
on the Knowledge and Attitudes Survey Regarding pants. Identifying nurses’ pain knowledge and pa-
Pain in this study was within the range of mean scores tients’ pain intensity experiences through research
reported in other studies. The consistent findings sug- can be a means of improving patient outcomes by iden-
gest that improvement is needed in nurses’ knowledge tifying issues related to patient care that need
regarding pain management. Also, the results in this improvement.
study indicated that patients experienced moderate
pain intensity. This finding was also consistent with
findings in other studies.
A multidisciplinary approach is essential in the
management of patients’ postoperative pain.The provi- Results of this pilot study, the limitations, implications
sion of pain management educational programs for dis- for nursing practice, and future research were pre-
ciplines involved in the management of patients’ pain sented. The findings of the study are consistent with
is essential in improving staff knowledge. Integration other reported studies. Based on the findings of this pi-
of evidence-based practice from all disciplines involved lot study, there is a need to develop a multidisciplinary
in pain management is integral in improving patient evidence-based education program regarding postop-
outcomes. erative pain management at the study facility. Recom-
mendations also include the development of
Recommendations for Future Research processes to evaluate outcomes of pain management.
Recommendations for future research include replica- Replication of this study using a larger sample and
tion of this study with a larger sample and other other services is recommended.

Abdalrahim, M., Majali, S., Stomberg, M. W., & postoperative pain management in two hospitals. Journal of
Bergdam, I. (2010). The effect of postoperative pain Evaluation in Clinical Practice, 11(5), 444–451.
management program on improving nurses’ knowledge Institute for Clinical Systems Improvement (2008).
and attitudes toward pain. Nurse Education in Practice, Healthcare guideline: assessment of acute pain (6th ed.).
11, 250–255. Retrieved December 6, 2011, from http://www.icsi.org/
Bedard, D., Purden, M., Sauve-Larose, N., Certosini, C., & pain_acute/pain_acute_assessment_and_management_
Schein, C. (2006). The pain experience of post surgical of_3.html.
patients following the implementation of an evidence- Lin, L., & Wang, R. (2005). Abdominal surgery, pain and
based approach. Pain Management Nursing, 7(3), 80–92. anxiety: Preoperative nursing intervention. Journal of Ad-
Brown, C., Kristel, C., Bedard, D., & Purden, M. (2011). vanced Nursing, 51(3), 252–260.
Colorectal surgery patients’ status, activities, satisfaction, Matthews, E., & Malcolm, C. (2007). Nurses’ knowledge
and beliefs about pain and pain management. Pain Man- and attitudes in pain management practice. British Journal
agement Nursing. Retrieved October 21, 2011, from http:// of Nursing, 16(3), 174–179.
dx.doi.org/10.1016/j.pmn.2010.12.002. Melzack, R. (1975). The McGill Pain Questionnaire: Major
Eid, T., & Bucknall, T. (2008). Documenting and imple- properties and scoring methods. Pain, 1, 277–299.
menting evidence-based post-operative pain management in Melzack, R. (1987). The Short Form McGill Pain Ques-
older patients with hip fractures. Journal of Orthopedic tionnaire. Pain, 30, 191–197.
Nursing, 12, 90–98. Niemi-Murola, L., Poybia, R., Rhen, B., Makel, A., &
Ferrell, B., & McCaffery, M. (2005). Knowledge and atti- Niemi, T. (2007). Patient satisfaction with postoperative pain
tudes survey regarding pain. Retrieved April 12, 2006, from management—Effect of preoperative factors. Pain Man-
http://prc.coh.org. agement Nursing, 8(3), 122–129.
Gunningberg, L., & Idvall, E. (2007). The quality of post- Sloman, R., Rosen, G., Rom, M., & Shin, Y. (2005). Nurses’
operative pain management from the perspectives of pa- assessment of pain in surgical patients. Journal of Advanced
tients, nurses and patient records. Journal of Nursing Nursing, 52(2), 125–132.
Management, 15, 756–766. Wang, H. L., & Tsai, Y. F. (2010). Nurses’ knowledge and
Idvall, E., & Berg, A. (2008). Patient assessment of post- barriers regarding pain management in intensive care units.
operative pain management—Orthopaedic patients com- Journal of Clinical Nursing, 19, 3188–3196.
pared to other surgical patients. Journal of Orthopaedic White, P. F., & Kehlet, H. (2010). Improving postoperative
Nursing, 12, 35–40. pain management. Anesthesiology, 112(1), 220–225.
Idvall, E., Berg, K., Unosson, M., & Brudin, L. (2005). Wilson, B. (2007). Nurses’ knowledge of pain. Journal of
Differences between nurse and patient assessments on Clinical Nursing, 16, 1012–1020.