Knowledge, attitudes, and practices of transcutaneous electrical nerve stimulation in perioperative care: A Swedish web-based survey

1 Introduction

In contemporary acute pain management, multimodal analgesia is employed to address the complexity of pain and achieve effective pain relief [1,2]. Multimodal analgesia, often described as opioid-sparing pain treatment, involves the use of multiple analgesics or methods, including paracetamol/acetaminophen, non-steroidal anti-inflammatory drugs, and local anesthetics for wound infiltration, to target various pain pathways [3,4]. However, opioids remain integral to perioperative pain management despite side effects, such as sedation, nausea, and vomiting [5,6]. Additionally, 6–8% of opioid-naive patients risk developing long-term opioid use after surgery [7,8,9]. Consequently, there is growing advocacy for non-pharmacological and opioid-free pain management techniques [10,11,12,13,14,15].

Among the many therapies, transcutaneous electrical nerve stimulation (TENS) stands out as a noninvasive neuromodulation option. TENS delivers electrical currents through electrodes placed on the intact skin near painful areas. Its primary mechanism involves stimulating afferent A-beta nerve receptors, which reduce nociceptor cell activity and inhibit the transmission of noxious stimuli. Additionally, TENS can inhibit central nociceptor transmission by stimulating peripheral non-noxious afferents [16,17]. Furthermore, TENS is user-friendly and portable, extensively researched, and used for various painful conditions, including dysmenorrhea and chronic musculoskeletal pain [16,17,18,19,20]. It is effective for alleviating postoperative pain, reducing opioid consumption, and shortening post-anesthesia care unit stays for surgeries ranging from total hip replacements to laparoscopic cholecystectomies without side effects [21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36]. TENS is also used to manage conditions such as incontinence, constipation, and nausea [37]. Furthermore, TENS is cost-effective and ecologically sustainable due to its reusability, which helps reduce healthcare waste and carbon footprint [38,39,40]. Patients can also independently use TENS, enhancing their autonomy, control, and involvement in their care [41]. Despite these benefits, the perioperative use of TENS faces several challenges. Effective application often requires personalized electrode placement and settings, which can be complex and time-consuming [42,43]. Additionally, expert panels offer inconsistent guidelines on TENS in perioperative settings, leading to variability in its application [44]. Multimodal pain management is often interpreted as polypharmacy, potentially overshadowing non-pharmacological interventions like TENS [44].

The perioperative environment is complex, involving multidisciplinary teams and synchronized teamwork. Implementing technologies such as TENS in this setting requires careful planning and strategy to address practical aspects such as training, equipment management, and consistent clinical practice [45,46]. Effective use of TENS also requires education for both patients and healthcare professionals (HCPs) on its benefits, usage, and potential outcomes. This includes educating staff in TENS administration and educating patients on its role in pain management [45,46,47]. Patient and staff education is crucial to overcome knowledge barriers and improve acceptance. A recent study emphasizes the importance of person-centered education and highlights how understanding TENS enhances both its effectiveness and patient autonomy [48].

Previous studies have primarily focused on the efficacy of TENS, with limited exploration of the practical challenges and perceptions that HCPs face in their perioperative implementation. By identifying these barriers and facilitators, this study seeks to provide insights that can inform the development of targeted educational programs and organizational guidelines to increase TENS use in clinical practice.

2 Methods

This study aimed to assess the knowledge, attitudes, and practices (KAP) of HCPs regarding TENS in perioperative settings, with the goal of promoting its integration into routine clinical practice.

A web-based survey was chosen for its efficiency in collecting data collection from a large and geographically dispersed sample while ensuring anonymity and convenience for participants. In October 2023, an email containing an information letter describing the project and a link to the survey was sent to the heads of anesthesiology departments in all university hospitals in Sweden (n = 7) and three smaller, which were randomly selected from a list of hospitals that expressed interest after receiving the information letter. Their names were drawn by A.O. from a bowl to ensure an unbiased selection, representing each of the country’s three geographical areas: Northern Sweden (north of Uppsala), Central Sweden (between Uppsala and Linköping), and Southern Sweden (south of Linköping). Department heads served as gatekeepers for survey distribution, leveraging their leadership positions and ability to facilitate communication within their departments, ensuring the survey reached HCPs, including anesthesiologists, nurse anesthetists, critical care nurses, and registered nurses with basic education in their clinics. The survey remained open until January 2024, with reminders sent after 4 and 8 weeks.

The e-mail addresses of the department heads were sourced from Sweden’s national healthcare guide website (www.1177.se) [49]. The survey was conducted using the Qualtrics platform (version 2023-10-2024-01) procured by the University of Gothenburg. Participants voluntarily provided individual consent and completed the survey anonymously.

3 Results

Based on feedback from the department heads, the survey was distributed to 870 HCPs, yielding 246 responses (28% response rate). Over 78% of the respondents had ≥7 years of experience in perioperative practice, 61% were women, 71% were aged ≥41 years, and 83% worked at a university hospital. The demographics of the respondents are presented in Table 1.

3.2 Attitude toward TENS

In assessing attitudes toward TENS effectiveness for acute postoperative pain, 30% of respondents were certain of its effectiveness, while 53% were uncertain (Figure 1). Responses varied significantly by profession (H(3) = 13.64, p = 0.003), with anesthesiologists showing higher agreement regarding attitudes toward the effectiveness of TENS than other professions. Post hoc comparisons revealed a significant difference between anesthesiologists and nurse anesthetists (adjusted p = 0.02), with anesthesiologists showing higher agreement regarding the effectiveness of TENS. No significant differences were observed across sex, age, workplace, or years of experience (Supplementary Files 2 and 3, Q.3.6).

Figure 1

Respondents’ attitudes regarding the effectiveness of TENS therapy for acute postoperative pain relief. TENS, transcutaneous electrical nerve stimulation.

When questioned about their interest in developing both theoretical knowledge and practical skills for using TENS, approximately 60% of the respondents responded as agree or strongly agree. In contrast, about 36% responded as disagree or strongly disagree (Figures 2 and 3).

Figure 2

Respondents’ interest in developing theoretical knowledge about TENS. TENS, transcutaneous electrical nerve stimulation.

Figure 3

Respondents’ interest in developing practical skills in performing TENS. TENS, transcutaneous electrical nerve stimulation.

Interest in developing theoretical knowledge differed by sex (H(1) = 6.02, p = 0.01), with women expressing higher interest than men. Significant differences were also observed across professional roles (H(3) = 18.80, p < 0.001), with registered nurses with basic education showing the highest interest. Additionally, there were significant differences based on experience in perioperative practice (H(4) = 12.49, p = 0.01), indicating that HCPs with 0–2 years of experience exhibited the highest level of interest. No significant differences were observed in terms of age or workplace (Supplementary Files 2 and 3, Q.3.2).

Similarly, interest in developing practical skills for TENS varied by profession (H(3) = 22.28, p < 0.001), with anesthesiologists showing greater interest than other professions. Post hoc comparisons revealed a significant difference between anesthesiologists and critical care nurses (adjusted p = 0.00), with anesthesiologists expressing higher interest. Significant differences were also observed based on perioperative experience (H(4) = 12.32, p = 0.02), indicating that HCPs with 0–2 years of experience had the highest interest levels. No significant differences were observed across sex, age, or workplace (Supplementary Files 2 and 3, Q.3.3).

3.3 Practice of TENS

Regarding TENS application for postoperative pain, 79% of the respondents reported not using TENS, while 21% reported using it in practice. The results indicated a significant variation in the application of TENS therapy for postoperative pain across workplace groups (H(2) = 14.08, p < 0.001), with university hospital HCPs more likely to apply TENS therapy than those in county hospitals (adjusted p = 0.002). No significant differences were found between university hospitals and other hospitals/infirmaries (adjusted p = 0.24) or between county hospitals and other hospitals/infirmaries (adjusted p = 1.00). Furthermore, no significant differences were observed across sex, age, profession, or experience (Supplementary Files 2 and 3, Q.3.5).

3.3.1 Guidelines for TENS

When asked about the existence of TENS guidelines for managing postoperative pain at their clinics, 45% of the respondents reported none existed, 32% were unsure, and 23% confirmed the presence of guidelines. The presence of guidelines supporting TENS therapy varied significantly across the workplace (H(2) = 18.72, p < 0.001), with university hospital HCPs more likely to report the presence of guidelines than those at county hospitals (adjusted p = 0.00). Significant differences were also observed based on profession (H(3) = 12.23, p = 0.007), with anesthesiologists reporting the presence of guidelines more frequently than nurse anesthetists (adjusted p = 0.003). No significant differences were observed across sex, age, or years of experience (Supplementary Files 2 and 3, Q.3.4).

Among those confirming the presence of guidelines, 61% expressed satisfaction, either agreeing or strongly agreeing (Figure 4), with satisfaction levels varying significantly across professional roles (H(3) = 10.36, p = 0.016). Registered nurses with basic education showed the highest satisfaction levels. Pairwise comparisons revealed significant differences between anesthesiologists and critical care nurses (p = 0.02), anesthesiologists and registered nurses with basic education (p = 0.035), nurse anesthetists and critical care nurses (p = 0.02), and nurse anesthetists and registered nurses with basic education (p = 0.04). However, these differences were not significant after adjustment (adjusted p = 0.09, 0.21, 0.13, and 0.26, respectively). No significant differences were observed across sex, age, or years of experience (Supplementary Files 2 and 3, Q.3.4.1.2).

Figure 4

Satisfaction with clinic’s guidelines for TENS therapy. TENS, transcutaneous electrical nerve stimulation.

Among those who reported a lack of guidelines or were unsure about their existence, 39% agreed on the need for guidelines, while 14% disagreed and 47% expressed uncertainty. Years of experience showed significant variation (H(4) = 11.013, p = 0.026). Pairwise comparisons also indicated some differences, with differences between HCPs with 0–2 years and 12–14 years (p = 0.013) and between 3–6 years and 12–14 years of experience (p = 0.013). However, these differences were not significant after adjustment (adjusted p-values of 0.13 and 0.13, respectively). No significant differences were found based on age, sex, profession, or workplace (Supplementary Files 2 and 3, Q.3.4.2).

4 Discussion

Managing postoperative pain is complex, and there has been a longstanding advocacy for guidelines that promote multimodal analgesia to enable a more personalized and effective approach to pain relief [1,2,13,14,15]. Multimodal analgesia also seeks to reduce opioid use to avoid adverse effects and risks associated with long-term use, abuse, and misuse. Accordingly, keeping opioid use at low doses and short durations is beneficial to minimize these negative effects [7,8,9]. TENS is an effective adjunct to multimodal pain management across various types of surgeries, as it helps alleviate postoperative pain, reduces the need for pharmacological analgesia, and shortens the duration of care without adverse effects [21,22,23,24,25,26,27,28,29,30,31,32,33,34]. Despite these benefits, there has been a lack of research examining the KAP of HCPs regarding TENS use in perioperative care, marking this study as the first to address this gap.

The substantial knowledge gap among HCPs presents a critical barrier to TENS implementation in postoperative pain management. This gap is more pronounced in county hospitals than in university hospitals, suggesting disparities in access to education and resources that may affect patient care quality across different settings. Response bias may have influenced these findings, as the higher proportion of respondents from university hospitals (82.5%) could have skewed the data, potentially overrepresenting TENS knowledge and usage in these settings. Consequently, the findings may not fully reflect practices in county hospitals, where lower response rates may have led to an underrepresentation of their practices and challenges related to TENS adoption. This discrepancy implies that educational resources and training opportunities may be unevenly distributed, impacting the quality of postoperative pain management across different healthcare settings. The pervasive nature of the knowledge gap across all demographic groups underscores a systemic issue in perioperative care education, highlighting the need for widespread educational interventions targeting all HCPs, regardless of their backgrounds.

The limited clinical use of TENS reveals a disconnect between evidence-based recommendations and real-world application, potentially leading to suboptimal pain management outcomes. Significant differences in TENS application are evident across healthcare settings, with county hospitals and other hospital/infirmary workers reporting no TENS implementation compared to university hospital workers, underscoring disparities in access to resources and training. Response bias should be considered here, as the overrepresentation of university hospital HCPs, who may be more familiar with TENS, could affect the generalizability of our findings. Since most respondents were from university hospitals and fewer from county hospitals and other hospital/infirmary settings, the data may not fully reflect the overall situation across all facility types, potentially influencing the observed trends. This limitation suggests caution in generalizing findings to all healthcare settings, as the experiences and practices in county hospitals may differ significantly from those in university hospitals due to resource constraints and varying organizational priorities. Furthermore, this outcome aligns with observed knowledge gaps, reinforcing the need for widespread dissemination of TENS therapy education and resources. TENS offers an environmentally friendly alternative due to its reusability and ability to enhance patient involvement and autonomy in their care by allowing them to control and customize their pain management programs [37,38,39,40,41].

The absence and uncertainty of clinical guidelines for TENS use may contribute significantly to its underutilization, highlighting the need for the development and dissemination of clear, evidence-based protocols. This uncertainty was most pronounced among anesthesiologists and HCPs in county hospitals and other non-university hospitals/infirmaries. These findings underscore the importance of establishing clear guidelines to promote TENS usage in postoperative pain management.

The expressed interest among HCPs in enhancing their knowledge and skills presents a valuable opportunity for implementing educational programs. This universal interest indicates that such initiatives could have a widespread impact across diverse healthcare settings. However, approximately 36% of respondents expressed disinterest, resistance, or skepticism toward developing their theoretical or practical knowledge of TENS therapy. Thus, while there is considerable interest, efforts should also address these barriers to enhance and facilitate the effective use of TENS, ultimately improving postoperative patient care and outcomes.

One potential strategy to overcome these barriers is the application of nudging strategies, which can subtly influence HCPs to adopt new practices by making desired behaviors more accessible and appealing without infringing on autonomy [51,52]. Nudging could involve integrating TENS devices into standard postoperative care protocols, offering default TENS options in electronic health records, or placing prompts and reminders in clinical settings to encourage TENS consideration. By increasing TENS visibility and accessibility, HCPs may be more inclined to incorporate it into their practice. Nudging has gained recognition as an effective approach to improve decision-making and overcome the limitations of conventional methods such as guidelines, continuing medical education, and incentives [53]. Additionally, nudging has been successfully applied in various sectors, including healthcare, to promote safe and effective medication use and enhance adherence to clinical guidelines among HCPs [54]. In perioperative care, nudging could help bridge the gap between knowledge and practice, encouraging HCPs to incorporate TENS into multimodal analgesia regimens and thereby enhancing patient outcomes.

5 Limitations

This study had certain limitations. Although the response rate of 28% is relatively low, it is above average compared to many reported rates in healthcare surveys, which often report rates below 20% [55,56,57]. Nevertheless, this response rate may limit the generalizability of our findings and could introduce response bias; therefore, the results should be interpreted with caution. To improve response rates, we implemented literature-based strategies, such as email contact, two reminders, and ensuring that the survey could be completed in less than 10 min [58]. The study involved 246 HCPs with extensive perioperative experience; however, HCPs with greater interest or knowledge in TENS, particularly those in university hospitals, may have been more inclined to participate, potentially skewing the data and overrepresenting positive attitudes and practices regarding TENS. Additionally, distributing the survey through department heads may have introduced selection bias, as proactive distribution or encouragement by department heads in university hospitals could have led to higher participation than in county hospitals, potentially influencing our findings by disproportionately reflecting the perspectives of HCPs from university hospitals. Self-reported data may be subject to social desirability and recall biases. Furthermore, the study focused on a limited number of hospitals, including all university hospitals in Sweden and three randomly selected smaller hospitals across three geographical areas. This may not fully capture the diversity of perioperative practices regarding TENS across the country. However, including all university hospitals ensured coverage of major perioperative centers likely to have well-developed practices and resources, while the random selection of small hospitals aimed to provide a balanced representative sample of non-university settings.

Future research should aim for a larger, more diverse sample and a higher response rate, potentially incorporating interviews or focus groups to provide a more comprehensive understanding of TENS use barriers and facilitators in perioperative care. Additionally, using the KAP model, a post-intervention study with the same questionnaire could be conducted to evaluate the impacts of interventions designed to enhance TENS utilization.

6 Conclusion

This study underscores the limited use of TENS in acute postoperative pain management due to substantial knowledge gaps and the lack of clear guidelines. Although most HCPs expressed a strong interest in furthering their knowledge and skills of TENS, they reported inadequate knowledge and practical experience, which hampers its implementation in clinical practice. To address these challenges, we recommend that hospital leadership take specific actions. First, develop and implement comprehensive educational programs on TENS therapy, including workshops, training sessions, and integration into continuing medical education curricula. Second, establish clear, evidence-based clinical guidelines for TENS use in postoperative pain management. Hospital administrations should adopt these guidelines and ensure the availability of necessary resources, such as equipment and time allocation, to support HCPs in incorporating TENS into their practice. Additionally, policymakers should consider funding initiatives to support education and resource allocation for TENS implementation. Addressing these gaps is crucial for improving clinical practice and for empowering patients by promoting their involvement and autonomy in pain management strategies.