Evidence-Based Education Intervention to Improve Knowledge and Attitudes of Nurses' Postoperative Pain Management for Improved Patient Satisfaction

Monday, 9 November 2015: 2:05 PM

Gayle Ridgway, DNP, RN, APRN, CRNA
Private Contractor with Anesthesia Professionals / Georgia Institute of Plastic Surgery, North Dartmouth, MA, USA


            The purpose of this presentation is to demonstrate how to select and generate an evidence based education intervention for acute care nurses regarding postoperative pain management using a pretest-posttest design. The low scoring questions of the pretest were categorized into appropriate content areas using evidence-based practice (EBP) relating to postoperative pain management for the education intervention.   Patient satisfaction was monitored during the same timeframe of the pretest and posttest and assessed for trends.

            The Agency for Healthcare Research and Quality (AHRQ, 2012) recommends ongoing educational interventions for pain management that must be accomplished in order to maintain high standards of care for patients.  Evidence-based practice (EBP) models, including clinical practice guidelines, offer a framework for nurses to use when assessing and managing pain (Newhouse, Dearholt, Poe, Pugh, & White, 2007; Samuels & Fetzer, 2009).  The Johns Hopkins evidenced-based practice model provided the framework for this translational research project by guiding the identification of the necessary individual behaviors required to enhance pain management practices (Newhouse, Dearholt, Poe, Pugh, & White, 2007).

            Since pain management was recognized as a specialty in the 1980s, patients continue to be undertreated for pain with only one in four patients reporting their pain is under control (IASP, 2013; Wu & Raja, 2011).   Nurses’ knowledge and attitudes concerning postoperative pain management may be a barrier to adequate treatment.  Pain that is not well controlled can have physiological and psychological effects delaying or worsening patient outcomes.  The Center for Medicare and Medicaid (CMS) is now expecting patient satisfaction to impact the ratings that regulates reimbursement.  Patient satisfaction is reported through the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. 

            A review of the literature dating back to the 1970’s reveals a persistent need to improve postoperative pain management.  Historically, nurses’ knowledge, attitudes, and beliefs have significantly impacted the effectiveness of pain management.  A comparison of the practices from the 1970s to the present decade revealed contemporary pain management includes innovative multimodal therapies and advanced analgesics (White & Kehlet, 2010; Wu & Raja, 2011).  Yet the need to improve postoperative pain management and patient satisfaction continues to be documented in the literature (Wu & Raja, 2011).  Pain management has evolved to include guidelines to assess pain, recommendations on when to assess pain, the proliferation of various pain scales, and specific protocols to guide healthcare professionals, with the hope that these actions will capture and decrease any pain that patients are experiencing (Wells, Pasero, & McCaffery, 2008; Institute of Healthcare Improvement, 2013).  Even with all these recommendations, it has been noted that a major barrier with pain management stems from the nurses’ attitudes and knowledge in dealing with patients’ pain, subsequently impacting the delivery of adequate care (Clarke, French, Bilodeau, Capasso, Edwards, & Empoliti, 1996; Erkes, Parker, Carr, & Mayo, 2001; Young, Horton, & Davidhizar, 2006; Wang & Tsai, 2010; Schreiber et al., 2013).

            There have been many changes recently in postoperative pain management to include new multimodalities and advanced analgesics (Rognstad, et al., 2012).  As a result of their presence on the surgical units there is an increased demand for nurses to have greater proficiency in assessing and regulating these multimodalities.  Nurses are at the bedside assessing and managing patients and interpreting patient responses to pain (Ene, Nordberg, Bergh, Johansson, & Sjostrom, 2008; McHugh & Stimpfel, 2012). These nurses are the ideal group of healthcare professionals to make the biggest difference on pain management, patient outcomes, and patient satisfaction (McNamara, Harmon, & Saunders, 2012; Rugari et al., 2012). 

            Following IRB approval, this evidenced based education intervention was implemented on two surgical units using a pretest-posttest design to assess knowledge and attitudes of nurses’ postoperative pain management.  All questions that scored below 75% correct (n = 16) on the pretest were selected for inclusion in the education intervention.  These sixteen low scoring questions were examined and placed into three categories that corresponded with three objectives for professional nurse behavior regarding pain management by the International Association for the Study of Pain (IASP, 2012).  These three categories:  pharmacology, pain assessment and management, and misbeliefs of drug seeking behaviors became the basis for the educational intervention and CEUs were applied for and offered to the nurses.  Additionally, qualitative data was collected to better understand nurses’ perceived barriers for effective pain management.  The nurses’ responses were coded and categorized into patient, provider, and systems factors.  Three most significant factors were identifying unrealistic pain expectations and knowledge deficits on the part of patient and providers, lack of time to assess pain properly, and cultural competence of providers as their perceived barriers.  Patients were interviewed about their pain and were administered the HCAPHS pain questions.  The nurses’ pretest-posttest results were analyzed using group means and paired t-tests, which showed a statistically significant increase in knowledge and attitudes on the nurses’ posttest (p ≤ .05).  It was also noted that patients reported less pain and had a longer mean timeframe between medication dosing when multimodal pain management was used.  One of the survey units demonstrated an increase in patient satisfaction in their three HCAPHS pain questions with the use of these multimodalities. 

            As a result of the findings of this study, recommendations were made to continue this educational intervention to all healthcare professionals in all units and continue to measure the impact on patient outcomes and satisfaction.  A recommendation was made and later implemented to have a “medication of the week” program on the units for the nursing staff.  Medication deficiencies that were identified in the pretest were converted into posters and placed on the units. There were discussions of their pharmacodynamics and pharmacokinetics, clinical applications, and issues. What this study has done differently from many other studies documented in the literature is to utilize the evidence-based model to categorize and build an educational intervention specifically targeting the low scoring questions. 

The results from the quantitative data generated by the pretest/posttest from the nurse participants combined with the data collected from the patient participant interviews increase the strength of the findings.  The research in pain control is ever evolving with new advances in pharmaceuticals, technology, and genetics research that demand a constant evaluation and re-evaluation of the literature and implementation into practice (Allegri, Clark, Andres, & Jensen, 2012).