Postoperative pain documentation in a hospital setting: A topical review

2.1 Design

An integrative review was chosen to carry out. It enables inclusion of various methodologies in one review, provides comprehensive understanding [36] and generates new knowledge of a research topic [37]. The review was performed following Whittemore’s and Knafl’s [36] 5-stage method, which provided a framework for the process. The phases of the process were to: (1) identify the research problem, (2) search the literature for data collection, (3) evaluate the studies, (4) integrate of the data and (5) synthesize and present the results.

2.2 Literature search

Relevant studies were identified by searching electronic databases: Web of Science, PubMed/Medline, CINAHL, Embase, Ovid/Medline, Scopus and Cochrane Library. The search was finalized by scanning the reference lists of the relevant publications. Search terms pain and documentation were used in different variations (Appendix. 1). The search resulted in 2209 articles (Fig. 1). The first author (KH) reviewed all the titles. The abstracts and full texts were independently reviewed by two authors (KH, L-MP). At this point, the inclusion criteria were reappraised; hereafter, the focus was on postoperative pain instead of acute pain in general. Disagreements were discussed until consensus was reached. A total of 17 studies met the criteria. After a quality assessment of the studies and a reappraisal of inclusion criteria, 10 studies were included into the analysis. Six of the excluded studies were considered to be too old, as the time margin was decided to be 10 years. One study was excluded based on its low quality assessment score.

Fig. 1

Flow diagramofstudyselection.

2.3 Inclusion and exclusion criteria

Inclusion criteria:

• original study report

• written in English

• about acute postoperative pain

• examining adult patients (over 18 years)

• focusing on documentation (nurses or physicians)

• taking place in a hospital environment

Exclusion criteria:

• not peer reviewed scientific reports

• an abstract without a full paper

• focusing on chronic pain

• lacking the minimum criteria for quality

2.4 Data extraction and synthesis

Three data extractions were done. Firstly, the details of study designs and processes were identified. Secondly, information was extracted about the auditing tools, different forms of postoperative pain documentation that were of interest and studies that examined information about pain. Information was collected about pain characteristics and management. Thirdly, information was extracted about postoperative pain documentation and auditing details.

2.5 Quality assessment

Two authors (KH, L-MP) independently assessed the quality of the selected studies. According to Whittemore and Knafl [36] there is no rigorous method for evaluating studies’ quality. The used quality assessment instrument was a two-part scoring system that included check-lists for both qualitative and quantitative research reports [38]. The check-lists for qualitative studies had 10 criteria and for quantitative studies 14 criteria (Tables 1 and 2). All items were rated with a four-point scale: yes=2points, partially=1 point, no=0 points and n/a (not applicable). A summary score was calculated for the studies by adding up the points and dividing the sum by the total possible score. A “not applicable” score was excluded from the calculation of the total score. Inter-rater agreement was calculated for the total scores based on the inter-class correlation coefficient (ICC) with a two-way mixed model, using IBM SPSS Statistics 22.0, to evaluate the consistency of the evaluations between the two authors. The ICC was good (ICC=0.736, 95% CI, p <0.005). Thereafter, the authors discussed differences in their evaluations and reached a consensus on the quality of each study.

The quality of the studies was good. Total summary scores varied between 0.8 and 1.0 (maximum score), with an exception of one study [39], which scored 0.65. All studies achieved maximum points for evidence and appropriateness of study design and all studies had some estimate of variance reported for the main results. Results were reported in sufficient detail, and conclusions were supported by the results. Subject characteristics were sufficiently described, and outcome and exposure measures were well-defined. The remaining assessed criteria had some variation in the scores.

3.1 Study designs in postoperative pain documentation research

Ten studies were included into the review (Table 3). Five studies were conducted in the USA [12, 40, 43], four in different countries outside Europe [39,44–46] and one in Sweden [47]. Mainly quantitative methods were used [12,39, 40, 41, 42, 43, 44, 45,47]; one study had a qualitative design [46]. The most commonly used study design was a descriptive retrospective patient-record review [12,40,41,44,45, 46], and seven studies used comparative approach [12,41, 42, 43, 44, 45,47]. The differences in documentation from day today [44,45] or nurses’ and patients’ assessments of the quality of postoperative pain management between those who had more pain than expected and those who did not, or the differences between nurses’ documentation and patients’ assessment of pain were compared[47]. There was also a comparison of documentation and pain management routines between hospitals [42]. One study evaluated the effect of an intervention: the implementation of a new pain assessment tool and its effect on pain assessment and documentation [39].

Sample sizes varied from 43 [46] to 425 [39]. One study did not reveal the sample size [43]. Data collection duration varied from 4 weeks [39] to 18 months [41]. Four studies did not mention the duration of the data collection, or stated that this was not relevant information [12,40,42,43]. All studies described the quality of post-operative pain documentation, and five studies assessed the quality of both, pain documentation and management [39,40,44,46,47].

3.2 Patient-record auditing details

Eight studies examined nurses’ documentation entries [12,39,40,41, 42,44,46,47], and two examined both nurses’ and physicians’ entries [43,45]. Length of auditing varied from 72h [44,45] to patient’s entire hospital stay [40,43]. Five studies did not report length of auditing or number of investigators [12,39,41,42,47]. In addition to these, one more study did not reveal how many investigators were auditing [46]. Number of reviewers varied from two to four. A variety of surgical specialities were represented, with orthopaedic and general surgery being the most common. Five studies were carried out in one hospital [39,40,45,46, 47], one in two hospitals [12], three in three hospitals [41,42,43] and one in six hospitals [44]. See Table 4.

Even though laws in many countries regulate documentation of care, only one study report mentioned that a law was guiding pain documentation [46]. All studies compared documentation to current regulations or guidelines. The Joint Commission and American Pain Society were the most frequently mentioned associations guiding documentation (Table 4).

3.3 Auditing tools and questionnaires used for pain management and documentation quality assessment

A variety of auditing tools were used (Table 5) in the studies to assess documentation in the patient records. All studies used different tools. The Pain and Anxiety Audit Tool (PAAT) was used to examine prescribed and administered medication and to describe nursing documentation of pain management [44]. The North American Nursing Diagnosis Association (NANDA) form was used to examine characteristics of acute pain in addition to patients’ self-reports, changes in vital signs and pain behaviour, such as restlessness or sweating. The comprehensiveness assessment tool was used to evaluate comprehensiveness of documentation by scoring it with a five-point scale [44]. One study used a 4-point scale with a 7-item audit form to assess accuracy, completeness, comprehensiveness and clarity of documentation [45]. The Pain Documentation Audit Tool was used to evaluate pain assessment, management and education information [46]. The Samuels Pain Management Documentation Rating Scale (SPMDRS) was used to assess documentation of pain assessments, interventions, reassessments and further interventions [12]. Four studies did not mention the use of auditing tools [40,41, 42, 43].

Two studies [39,47] used questionnaires to assess pain management. The Strategic and Clinical Quality Indicator in Postoperative Pain Management (SCQIPP) questionnaire has a 5-point scale with 14 items about communication, action, trust and environment. This questionnaire was used to examine patients’ assessments of qualityoftheir postoperative pain management [47].The questionnaire was modified to create a matching questionnaire to examine nurses’ views of how an individual patient’s pain care was carried out [47]. The Patient Pain Management Questionnaire, a 12-item instrument was used to examine patients’ satisfaction with pain assessment and management duringan ICU stay [39]. The Staff Satisfaction Questionnaire, a10-item instrument was used to examine nurses’ satisfaction with current practices for pain assessment and management in an ICU and their comfort level in assessing and managing pain of communicative and non-communicative patients [39]. Nurses were also asked about concernsor barriers to using the pain scale in an ICU. The End-of Study Questionnaire, an 11-item instrument was used to determine nurses’ satisfaction with training, utility and ease of use of the new pain assessment tool (the Nonverbal Pain Scale) [39].

A total of28 information details about pain were investigated in the studies (Table5), although none of the studies included the mall. The most comprehensively audited studies investigated 20 [40,44] or 21 [43] details. The most commonly examined details were pain assessment (in 8 studies), use of pain assessment tools (n=8), use of pain management interventions (n=8), reassessments (n=8), demographic information (n=9) and painintensity (n=6).Themost seldom explored information were pain duration (n=1), onset of pain (n= 1), patient’s self-report of pain (n= 2), anxiety level (n = 2) and nausea scale score (n=1).

3.4 Quality of postoperative pain documentation and management

All studies reported, that the quality of postoperative pain documentation did not meet the acceptable standards and that documentation should be improved (Table 4). Pain management education for nurses was suggested method for improving practice [44]. One study reported that more than 80% of pain documentation was unsatisfactory. The mean quality score was 1.4 on a scale ranging from 1 to 5, 5 representing the most comprehensive documentation [44]. In another study, the mean total audit score was 10.7 the maximum score being 28 [45].

Patients’ satisfaction and nurses’ documentation of pain assessment improved after the implementationofanew pain assessment tool, the Nonverbal Pain Scale, additionally patients’ pain was milder. Before the implementation, 55%of patients reported severe pain, and afterwards only 35% did. Moreover, after the implementation, nurses felt more confident in pain assessment; 81% felt confident or very confident [39]. Even though documentation improved, it was still notably below recommendations of the best practice guidelines.

Pain assessment was irregularly and inadequately documented [44,45,47]. There was a significant difference in documentation depending on the time after an operation; in 35% of the records pain management process was not documented during the first postoperative day. Medication was not documented in 53.7%, and outcomes of pain management were not documented in 15.2% of the records. On the second postoperative day, 46% of patients’ documentation included pain assessment. Pain assessment documentation was mostly lacking on the third postoperative day [44]. In the worst case, 0.5% of records achieved the hospital’s recommendations of regular pain assessment every 2–4h during the first 24h [45]. In another study, less than 50% of patient records contained pain assessment documentation [47].

Significant differences were found in pain documentation when wards in one hospital were compared [47]. Pain intensity was better-documented in a general surgery ward comparing to a thoracic surgery ward; 41% of general surgery patients’ pain intensity was documentedaccordingtothe hospital’s quality goals, when the corresponding number in the thoracic surgery ward was 6.7% [47]. The reason for thiswas likely the quality improvement programme, compulsory education and annual monitoring of documentation that were organized in the general surgery ward. Nurses did not have a realistic conception of their pain assessment and documentation skills; in the thoracic surgery ward, nurses believed that they assessed and documented pain according to the quality goals [47].

Nurses assessed patients’ worst pain less severe than patients themselves [47]. Patients who experienced more pain than they had expected preoperatively, were less satisfied with quality of pain management. Patients assessed quality of care higher than nurses. The authors believed that nurses knew, that they could have done better [47]. Nurses did not administer as many analgesics as had been prescribed even though patients’ pain had been assessed as moderate to severe, according to the documentation [46].

Those patients to whom the importance of pain relief had been clearly explained were satisfied with how nurses and physicians had reacted to their pain [39]. They believed that professionals did their best with pain management.A connection between increased pain variability, less frequent assessment and more frequent interventions was found [41]. Older age and smaller surgical incisions was associatedwith lower pain but notashorterpain duration [42]. Even though reassessment of pain was rare, an important finding wasthatamorefavourable pain severitytrajectorycanbeachieved, if reassessment occurred within an hour after pain management intervention [42].

Some barriers to good pain assessment and management were found [39]. One barrier was related to physicians’ practices in pain management. Other barriers were inconsistent pain management and assessment and a need for education. The barriers included nurses’ beliefs and attitudes regarding their own competence to assess and manage pain. Further barriers were patients’ limited ability to express pain and concerns about overuse of pain medication [39].

3.5 Reported suggestions and recommendations for future research and practice

Several recommendations for future research and practice were proposed (Table 4). Nurses’ regular educational programmes should be developed to increase their knowledge of the latest scientific evidence of pain assessment and documentation [12,44, 45, 46] and to guide them to document more detailed [40]. Development of a monitoring system of documentation was recommended [44]. Nurses’ work burdens should be considered; clear guidelines or care plans for pain management and documentation would save time and provide suggestions about whattodocument [44]. Guidelines and recommendations should bebasedonthe latest evidence, and they need to be strategically and systematically implemented [46].

Qualitative studies with interviews or observations were proposed [46,47] to improve quality of pain management, to identify differences’ in pain management and documentation and to influence nurses’ decisions [46]. Studiesto reveal the best pain documentation practices [43] and hospital-level factors that impact pain outcomes were requested [41].

Patients’ preoperative education, should be carefully considered, as pain expectations can be influenced by the information given to them. Previous pain experiences and individual aims in pain management need to be taken into account [47]. Effects of postoperative pain management methods should be examined using larger samples and a greater variety of surgical types [41].

All patient groups should have equally satisfactory pain management. For example, patients withneurologicalimpairmenthave deficiencies in their pain management, due to nurses’ concerns about side effects of opioids, such as low blood pressure [39]. This shouldbe exploredin more detailtoimprove pain management for this patient group [39].