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PAIN MANAGEMENT

Pain management and satisfaction in postsurgical patients Jennifer Tocher, Sheila Rodgers, Margaret AC Smith, Deborah Watt and Lesley Dickson

Aims and objectives. To examine the relationship between patient satisfaction and the incidence of severe and enduring pain through a health board wide hospital satisfaction questionnaire. Background. The incidence and management of acute postoperative pain and its relationship to patient satisfaction have been of great interest to clinicians over the last 20 years. Evidence suggests that despite many moves to address this problem with the advent of acute pain nurse specialists and dedicated pain teams, severe and enduring pain continues to be a problem. However, patients appear to report high satisfaction levels. Design. The study design was a postal questionnaire the results of which were analysed statistically. Methods. The postal questionnaire was sent to patients who had been discharged from acute hospitals in one health board in the previous two weeks. A total of three large acute hospitals were included. The data were analysed to produce descriptive statistics for all patients on the pain questions and then for patients with severe and enduring pain on the variables of age, gender, ethnic group, responses to pain questions and type of admission. Results. Twenty-six percent of patients reported having pain all or most of the time. Patients suffering from severe and enduring pain were younger females. Conclusion. Acute postoperative pain continues to be a problem, although patients continue reporting moderate satisfaction levels. Relevance to clinical practice. Acute postoperative pain is an ongoing issue for postsurgical patients. It is crucial to understand and recognise issues that can adversely contribute to increased pain severity. Key words: patient satisfaction, postsurgical pain, severe and enduring pain Accepted for publication: 12 May 2012

Despite advances in modern medicine, specifically anaesthetics, acute pain following surgery is a common and not unexpected condition (Shoenwald & Clark 2006). Effective and safe pain management free from unwanted side effects continues to present a major challenge to acute care staff

(Carr et al. 2005). The advent of acute pain teams has improved the overall management of pain in acute settings, most notably in large general hospitals (McDonnell et al. 2003, 2005). Nonetheless, pain management is known to be a significant and recurring source of dissatisfaction for patients (Jensen et al. 2004, Kim et al. 2005, Roth et al. 2005).

Authors: Jennifer Tocher, PhD, BSc, RN, Lecturer, Nursing Studies, School of Health in Social Science, Old Medical School, University of Edinburgh, Edinburgh; Sheila Rodgers, PhD, MSc, BSc, RGN, Senior Lecturer, Nursing Studies, School of Health, Old Medical School, University of Edinburgh, Edinburgh; Margaret AC Smith, PhD, MSc, DANS, RNT, RM, RGN, Lecturer, Division of Nursing, Occupational Therapy and Art Therapies, Queen Margaret University, Musselburgh; Deborah Watt, RGN, RSCN, RNP, Advanced Nurse Specialist – Pain

Management, Lothian Health, Anaesthetics, Western General Hospital, Edinburgh; Lesley Dickson, RGN, RSCN, RNP, Advanced Nurse Specialist – Pain Management, Lothian Health, Anaesthetics, Western General Hospital, Edinburgh, UK Correspondence: Jennifer Tocher, Lecturer, Nursing Studies, School of Health in Social Science, Old Medical School, University of Edinburgh, Teviot Place, Edinburgh EH8 9AG, UK. Telephone: +44 0131 651 1991. E-mail: [email protected]

Introduction

Ó 2012 Blackwell Publishing Ltd Journal of Clinical Nursing, 21, 3361–3371, doi: 10.1111/j.1365-2702.2012.04253.x

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A substantial number of studies have examined the patient’s experience of postoperative pain; the majority of which have highlighted that levels of postoperative pain remain unacceptably high (Wilder-Smith & Schuler 1992, Watt-Watson et al. 2001, MacLellan 2004). This situation has been described as unacceptable by many working in the field of postoperative pain (Schafheutle et al. 2001, Al Samaraee et al. 2010, Wadensten et al. 2011). Unresolved acute pain can have psychological, physiological and socioeconomic consequences for patients (RCA & the Pain Society 2003, Macintyre & Schug 2007) and can lead to the development of chronic pain (Perkins & Kehlet 2000, Kehlet et al. 2006, Macrae 2008, ANZCA 2010). It is well established in the literature that patients expect to have pain postoperatively (Brockopp et al. 1996, Closs 1996, Joelsson et al. 2010). Alongside, these concerns, patient satisfaction with care and improvement in health status, have become important criteria for quality of care assessment and have been given greater emphasis by the National Health Service (NHS). However, the relationship between satisfaction and quality of care received is complex and affected by patient, doctor and service factors (Chow et al. 2009). Pain management following invasive procedures is considered a crucial issue when evaluating the value of interventions provided by the healthcare team (Carlson 2008).

using interview and some observational research studies (Manias et al. 2004). Nurses’ pain assessments and strategies for managing patients’ pain are often suboptimal (Rodgers 2000, Schafheutle et al. 2001, Manias et al. 2002, Wadensten et al. 2011), whilst other studies have found that doctors often do not have sufficient knowledge and experience in acute pain management (Sandhu et al. 1998, Rupp & Delaney 2004). More assessment equals better pain management is a commonly accepted and relatively unchallenged maxim within the pain community and literature. Provision of high-quality care is the common end point for most clinicians; however, there still remain inconsistencies in the level of this quality provision across healthcare settings (Chow et al. 2009). There are many different factors that can influence whether or not an individual is content with the service that they receive during a hospital admission (Jibodh et al. 2009) with pain management being a small part of this larger picture. The significant Pain After Surgery report (Royal College of Surgeons England and Royal College of Anaesthetists 1990) highlighted evidence of the incidence of postsurgical pain but noted that patients in the same studies reported satisfaction with care, suggesting they regarded postsurgical pain as unavoidable.

Expectation and pain management

Pain can be defined as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage’ (RCA & the Pain Society 2003, p. 2). Acute pain linked to acute injury, including surgery or disease, is normally of short duration, whereas chronic pain refers to pain that has lasted more than three months or beyond the expected recovery time after injury or disease (RCA and The Pain Society 2003). Chronic postsurgical pain (CPSP) has been defined as pain commencing after a surgical procedure, experienced for at least two-month duration, in which other causes of pain (malignancy, chronic infection) have been ruled out, and where the pain is not attributable to a preexisting condition (Macrae 2008).

Pain is multidimensional (Richards & Hubbert 2007); therefore, there are likely to be complex, experiential and situational processes at work with regard to how patients perceive or experience pain. Patients’ expectations, for example, appear to concord with their subsequent pain, but are not considered relevant to satisfaction, nor to their subsequent recovery (Linde et al. 2007). McKinley et al. (2002) speculated that patient expectation of care they will receive has an important impact on satisfaction. Patients with high expectations may be dissatisfied with optimal care and those with low expectations may be satisfied with deficient care. A variety of factors also appear to influence information–giving in relation to preparing patients for pain, for example, gender, who, when, person-based factors, type of information (Campbell et al. 1999). In this respect, there are no studies currently available on different individuals’ involvement and subsequent impact upon information giving in relation to pain expectation, for example, doctors vs. nurses.

Satisfaction and pain management

Resources and pain management

Assessment of pain is a common theme in the pain assessment and management literature and has been explored mostly

Acute pain teams (APTs) are now a relatively common feature of large general hospitals (McDonnell et al. 2003).

Background Definitions of pain in this study

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Pain management

Acute pain services can be configured as nurse-based services, anaesthetist led with the support of APT nurses or they may comprise multidisciplinary teams including APT nurses and 24-hour anaesthetist cover (Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine 2010). A postal survey of 403 NHS hospitals in the UK found large variations in acute pain services provision (Powell et al. 2004), and in a later paper, the same authors argued that the implementation of national policies could be hampered by a range of interacting factors such as the local organisational setting, and the beliefs and attitudes of the varied staff group (Powell et al. 2009). APTs have emerged in response to a variety of factors namely changes in healthcare delivery, organisation and medical advances (day surgery, epidurals, high dependency units, patient-controlled analgesia). Arguably, there may also be evidence of suboptimal pain management across large heterogeneous settings. Whilst these APTs have improved the overall management of acute pain in those settings (McDonnell et al. 2005), pain remains a constant and unremitting feature of patient complaints. Other resource issues, such as staff–patient ratios, bed management policies and skill-mix, may also play a part in the success or otherwise of acute pain management. These factors, however, remain as yet, unexplored. This study seeks to explore the aforementioned factors using patients’ perspectives on pain management as the fulcrum with which to further uncover the complex relationship of pain, assessment, expectation and resourcing.

User involvement and pain management – the picker database The concept of user involvement is rightly given considerable emphasis by UK Government policy (Beresford 2007). The local health provider in this study is committed to engagement with service users and the public through its Patient and Public Partnership Strategy. This includes a Patient and Public Partnership Network, Patients’ Forum and Family Council. A key element of engaging with service users is through an extensive postal survey using a methodology and questionnaire – the National Patient Survey (NPS), which was developed by the Picker Institute. The founder of the Picker Institute, Harvey Picker, was the president and chairman of a major healthcare X-ray equipment company in the USA. After observing the care his wife received for an incurable illness, he founded the Picker Institute in 1986. Assisted by Harvard University Academics, the Picker Institute developed comprehensive surveys for eliciting patients’ views of their care in the USA. The work was extended to Germany and Switzerland. The Picker Ó 2012 Blackwell Publishing Ltd Journal of Clinical Nursing, 21, 3361–3371

Pain management and satisfaction

Institute Europe (a charity and limited company) was established in the UK in 2000 (Picker Institute Europe 2011). The Picker Institute contributed to the NHS National Patient Survey program in England through the Commission for Healthcare Improvement, now the Care Quality Commission, and it has undertaken surveys for many NHS Trusts. For example, Christie (1999) described how a Health Board in Scotland planned to use Picker Institute Survey data from their patients to improve hospital services; the NHS National Patient Survey is now used across England and Scotland. Rather than being a satisfaction survey, the NPS questions are framed to answer ‘what happened?’ These questions were shown to provide a much more accurate picture of the care provided to patients (Bruster et al. 1994). The Picker Institute developed instruments that seek detailed information on patients’ experiences of health care. These questionnaires are focused on specific dimensions of patient care—including information and communication, coordination of care, respect of patient preferences, involvement of family and friends, and continuity and transition (Bruster et al. 1994). The Picker instruments avoid asking whether patients were satisfied with their care and address issues of particular salience to patients. The content of the measures is built upon qualitative in-depth interviews with patients and focus groups (Bruster et al. 1994). A database retains the responses to the postal survey. Pain management is viewed as a potential indicator of quality of care. (Scottish Government 2004, Wadensten et al. 2011) noted that questions about pain management are often included in patient satisfaction surveys in the USA and in Sweden. In the last patient survey by the local health provider area in the UK, pain was identified as a significant issue for patients. The Patient Forum then identified pain management as one of the ongoing strategic priorities. The survey data were analysed for all inpatients giving a mean rating score of 100% being a perfect score and lower scores indicating a poorer rating. Questions on the severity and duration of pain were ranked as the bottom two of all questions in the survey in this analysis. Analysis at ward level also seemed to indicate the patients in surgical wards had a worse pain experience. Pain in surgical patients then was highlighted as a major area of consideration by the Patients’ Forum.

Aims and objectives of the study The aim of this study was to identify and characterise surgical patients who report severe and enduring pain (SEP) and to identify demographic variables associated with patients who report SEP. SEP was identified in patients when they reported

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having pain almost all of the time during their hospital admission and that the level of pain experienced was severe. The research questions were: 1 What are the prevalence and characteristics of patients reporting SEP in surgical settings? 2 What demographic variables are associated with reporting SEP in surgical settings? The study involves the statistical analysis of an existing data set. The data set is from a Patient Perspective survey that was undertaken in 2006 for all inpatient areas in one NHS Health Board in Scotland. This survey is based on the NPS with some additional questions on pain. Data analysis aimed to show the demographic breakdown of the surgical patients by level of pain reported. Further inferential statistics were used to test out any associations between reports of SEP and the demographic variables. Patients who participated in the original survey gave their consent to the use of these data for analysis and service development. The personal data held on the database are fully anonymised and information cannot be traced to individual patients. The study was presented to the local research ethics committee and the local Research and Development committee to inform them of this further analysis of the data and this was approved.

Sample In the original survey, a random sample of patients from across a range of hospitals, wards and departments in one Health Board was taken. A total of 5934 eligible patients were selected and mailed out questionnaires following discharge from hospital. Two reminders were sent to nonresponders to achieve a response rate of 65Æ9% (n = 3909). In this secondary analysis, the inclusion criteria for patients being selected for study from those who returned questionnaires were; patients aged 18 or over discharged from hospital in one NHS Board during May 2006 who returned their completed postal questionnaires and reported having an operation or procedure. Patients were excluded if they were aged 17 and under, were discharged from day surgery wards/units or were patients in paediatric wards/ hospitals. The surgical patients were identified by their response to a question on whether they had had an operation or procedure during their stay in hospital. Within the Health Board, three hospitals provided surgical services. They covered a range of general surgical and specialist surgical areas such as neurology, orthopaedics, cardiothoracic, breast and gynaecology. For surgical areas across three hospital sites, a total of 2269 patients were identified.

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Methods The original survey was carried out as a postal questionnaire to patients who had been discharged from acute hospitals in one health board in the previous two weeks. A total of three large acute hospitals were included. Non-responders were followed up with a reminder at two weeks and then again at a further two weeks if still no response had been received. The questionnaire comprised 40 questions relating to a variety of themes and was in the main, based on the same questionnaire now used in the NPS in England and Scotland. The questionnaire asked about patient experiences and satisfaction with a range of areas including; safety and quality of care, information and choice, building relationships, cleanliness, comfort and friendliness, access and waiting times, and questions about any operations or procedures. Demographic details within the data set are gender, age group, ethnic group, ward, type of ward, whether the patient had an operation or not, type of admission (planned or emergency) and pain. In this questionnaire, further questions about the nature of the pain experience were added, which enables the analysis of the patients’ pain experience. With regard to pain management, the five questions were the following: 1 Were you ever in any pain? 2 During your stay in hospital, how much of the time were you in pain? 3 When you had pain, was it usually severe, moderate or mild? 4 Do you think the hospital staff did everything they could to help control your pain? 5 Overall, how much pain medicine did you get? Patients who had undergone surgery were identified by their answer to the question ‘During your stay in hospital, did you have an operation or procedure?’. It might have been possible to identify patients in designated surgical wards but not all would have undergone surgery. However, identifying surgical patients through their answer to the above question also has its flaws in that it is open to interpretation by the patients as to what constitutes surgery or a procedure. The survey data were examined for surgical patients who had SEP. Patients were identified as having SEP if they stated in their questionnaire that they had pain most or all of the time and that pain was usually severe. Combining these responses led to the creation of a new variable – SEP. These patients were characterised and compared to other surgical patients without SEP. A total of 2269 surgical patients from the survey were included in the analysis. Ó 2012 Blackwell Publishing Ltd Journal of Clinical Nursing, 21, 3361–3371

Pain management

The data were analysed to produce descriptive statistics for all patients on the pain questions and then for patients with SEP on the variables of age, gender, ethnic group, responses to pain questions, type of admission (planned or emergency) and overall satisfaction with care. These responses were compared to those of all other surgical patients to look for statistically significant differences. A chi-square test was used for comparison on nominal variables, whereas a t-test was used to compare SEP and non-SEP patients on age. The views of patients with SEP on other aspects of their care which were identified as potentially related to their pain experience were compared to the views of all other surgical patients using a Mann–Whitney U test for ordinal data and the chi-square test for binomial or nominal data.

Findings Of a total of 2269 surgical patients, 68Æ9% (1564) had experienced pain at some time during their hospital stay (Fig. 1). Just over half of the surgical patients reported having pain some of the time during their hospital stay, whereas 26Æ3% (410) had pain for all or most of the time, and 22Æ8% (357) had pain only occasionally (Fig. 2). Patients were asked how severe their pain usually was during their hospital stay rather than about pain at its worst or immediately after surgery. 38Æ4% (596) reported severe pain and 52Æ1% (809) had moderate pain, whereas only 9Æ4% (145) reported mild pain (Fig. 3). Patients were asked to what extent they thought hospital staff did everything they could to help control the pain. The vast majority felt that staff had done everything they could to help them with pain (Table 1 and Fig. 4). On the whole, patients reported they were given adequate pain medication despite the levels of pain reported. Eighty-six percent (1345) said they were given enough pain medication with few having not enough (12Æ8%, 199) or too much (1Æ0%, 16) (Table 2). Once pain questions had been examined for all surgical patients, the new variable of SEP was created to identify patients who reported having severe pain all or most of the time. Out of all surgical patients, 12Æ3% (278) had SEP (see Fig. 5). Surgical patients with SEP were more likely to be woman than man (chi-square test = 13Æ9, df = 1, p < 0Æ001). 64Æ4% (179) of patients with SEP were women, whereas only 52Æ5% (1044) of all the other patients were women (Table 3). Patients with SEP were more likely to be emergency admissions than other surgical patients (chi-square test = 18Æ3, df = 2, p < 0Æ001). 45Æ3% (126) of patients with SEP Ó 2012 Blackwell Publishing Ltd Journal of Clinical Nursing, 21, 3361–3371


1600 1400 1200 1000 800 600 400 200 0

Yes

No

Figure 1 Were you ever in any pain?

800 700 600 500 400 300 200 100 0

All or most of the time

Some of the time

Occasionally

Figure 2 During your stay in hospital, how much of the time were you in pain?

900 800 700 600 500 400 300 200 100 0

Severe

Moderate

Mild

Figure 3 When you had pain, was it usually severe, moderate or mild?

were emergency admissions, whereas only 35Æ3% (676) of other surgical patients were admitted as an emergency (Table 4). The average age of surgical patients in this study was 59 years (see Fig. 6). With regard to age, patients with SEP were on average significantly younger than those without SEP, having an average age of 54 in comparison with an average age of 61 for other patients (t-test F = 0Æ569 p < 0Æ0001). Overall, there was little variation in ethnic group in the sample (see Table 5) with the vast majority stating their ethnic group as ‘White’. Only 1Æ5% of surgical patients were non-White. There was no significant difference in the ethnic group reported by patients with SEP and other patients. Whilst most surgical patients seemed to be relatively content with pain management, the experiences of Patients with SEP were somewhat different. Patients with SEP were

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J Tocher et al. Table 1 Do you think the hospital staff did everything they could to help control your pain?

Yes, definitely Yes, to some extent No Total

n

%

Percent

1109 371 79 1559

48Æ9 16Æ4 3Æ5 68Æ7

71Æ1 23Æ8 5Æ1 100Æ0

Severe & enduring pain 12.3%

1,200 1,000

Series1

Other 87.7%

800 600

Figure 5 Percentage of patients with severe and enduring pain.

400 200 0

Yes, definitely

Yes, to some extent

Table 3 Sex of patients with SEP and all others

No

Figure 4 Do you think hospital staff did everything they could to help control your pain?

Table 2 Overall, how much pain medicine did you get?

Enough Not enough Too much Total

Female (%)

Total

946 (47Æ5) 99 (35Æ6)

1044 (52Æ5) 179 (64Æ4)

1990 278

Table 4 Type of admission

n

%

1345 199 16 1560

86Æ2 12Æ8 1Æ0 100Æ0

much more likely to disagree with the view that hospital staff did everything they could to help control their pain (X2 = 02Æ6, df = 2, p = 0Æ000; see Table 6). Patients with SEP were also much more critical of the amount of pain medication they received. Whereas 91Æ5% of all other surgical patients who had experienced some pain felt they had received enough pain medication, only 61Æ2% patients with SEP felt they had received enough. Conversely, 37% of patients with SEP said they did not get enough pain medication, whereas only 7Æ6% of all other patients felt they did not get enough. (v2 = 177Æ6, df = 2, p = 0Æ000; see Table 7).

Discussion Patients in this study continue to report high levels of postoperative pain, which is consistent with the current literature. Almost 70% had pain at some point during their hospital stay with almost 40% usually experiencing severe pain. Yet the vast majority of patients felt that staff had done all they could to help them and that they had received

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All others SEP

Male (%)

All others SEP Total

Planned in advance

Emergency

Something else

Total

1216 (61Æ6%) 150 (54Æ0%) 1366 (60Æ7%)

676 (34Æ3%) 126 (45Æ3%) 802 (35Æ6%)

81 (4Æ1%) 2 (0Æ7%) 83(3Æ7%)

1973 278 2251

sufficient pain medication. There is increasing evidence that patients report ‘satisfaction’ with pain relief despite reporting high pain scores or severe pain (Carlson 2008). Thus, ‘satisfaction’ may be a negligible or irrelevant end point as far as pain management is concerned (Svensson et al. 2001, Idvall 2002). Just over 12% of patients in this study were found to have severe pain for all or most of their stay in hospital. This may not seem like a large percentage, but since 1990 when the Royal College of Surgeons England and Royal College of Anaesthetists (1990) reported a high incidence of unrelieved postoperative pain, there have been a number of initiatives, such as acute pain teams, around postoperative pain management. It may be that the impact of such initiatives is that pain management has improved and satisfaction is relatively high yet there are still high levels of unrelieved pain. Or that there is a greater awareness of pain and pain management by both ward staff and patients, and therefore patient expectations of pain have increased. A prospective randomised controlled trial study by Lang et al. (2005) on patient– provider interactions during an invasive procedure suggests a Ó 2012 Blackwell Publishing Ltd Journal of Clinical Nursing, 21, 3361–3371

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Pain management and satisfaction Table 6 Do you think the hospital staff did everything they could to help control your pain?

Number

300

200


Yes, definitely

Yes, to some extent

No

Total

967 (75Æ5%) 138 (50Æ5%) 1105 (71Æ1%)

278 (21Æ7%) 94 (34Æ4%) 372 (23Æ9%)

36 (2Æ8%) 41 (15Æ0%) 77 (5Æ0%)

1281 273 1554

100

Table 7 Overall, how much pain medicine did you get? 0

25.00

50.00

75.00

100.00

Enough

Not enough

Too much

Total

1173 (91Æ5%) 167 (61Æ2%) 1340 (86Æ2%)

98 (7Æ6%) 101 (37Æ0%) 199 (12Æ8%)

11 (9%) 5 (1Æ8%) 16 (1Æ0%)

1282 273 1555

Age


Figure 6 Age of all surgical patients.

Table 5 Ethnic origin All surgical patients

n

%

White Black or Black British Asian or Asian British Mixed Chinese Other ethnic group Total Missing Total

2217 6 12 9 4 3 2251 18 2269

97Æ7 0Æ3 0Æ5 0Æ4 0Æ2 0Æ1 99Æ2 0Æ8 100Æ0

nocebo effect or negative affective priming mechanism may play a part in how patients experience and subsequently rate their experience. They suggest that a self-fulfilling prophecy is evident, namely warn patients of pain and sympathise, pain is expressed, which provides justification, and a subsequent repeat of the behaviour. Patients in our study who experienced SEP were less satisfied with the amount of pain medication they received compared to others. Whilst these patients had severe pain for all or most of the time they were in hospital and were much more critical than other patients of their pain management, only 15% of them felt that staff had not done everything they could to control their pain, whereas half of patients thought staff had done everything they could. Peters et al. (2007) found that experiencing severe postoperative pain was one of the most important predictors for the development of chronic postoperative pain. Those with severe pain postoperatively also had poorer functioning, lower quality of life and lower global recovery. There are a number of other studies that support the finding that patients with severe postoperative pain are more likely to go on to develop chronic pain (Kalso et al. 1992, Aasvang & Kehlet 2005, Poleshuck et al. 2006). Katz et al. (1996) showed that Ó 2012 Blackwell Publishing Ltd Journal of Clinical Nursing, 21, 3361–3371

severe immediate postoperative pain was the only significant predictor of chronic postoperative pain. Ineffective pain management leads to increased patient morbidity, postoperative complications, delayed discharge, increased use of healthcare resources and may be linked to the development of CPSP (Macrae 2008). Patients who reported SEP were more likely to be emergency admissions rather than planned or elective surgical patients and to be woman rather than man. A study by Duncan (2011) found that surgical patients admitted as an emergency suffered higher pain scores. Emergency patients can be difficult to recruit to research studies that may limit the amount of work in this area. Emergency patients, owing to the nature of their admission process, have less time to be prepared for surgery and may also be more anxious. This might be an area for future research. In Duncan’s study, men were more likely to suffer severe pain than women. However, in this study and studies by Roseland and Stubhaug (2004) and Cepeda and Carr (2003), women were significantly more likely to experience severe pain than men. Patients in Duncan’s study were in the main gastroenterology surgery patients, whereas surgical patients in this study were included from all areas in the hospitals. Whilst there is some evidence that race and culture may interact with gender to influence the presentation of clinical pain (Greenspan et al. 2007), there was little variation in ethnicity of respondents in this study. However, the size of the minority ethnic population of Scotland constituted 2% of the total population in an analysis of the 2001 census that was replicated in this study with 98% of all respondents stating their ethnic group as white. This study clearly demonstrated the tendency for younger patients to report higher levels of SEP. Generally, studies report lower levels of postoperative pain in older patients

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(Melzack et al. 1987), although there are some studies where this association has not been found (Zalon 1989, Duggleby & Lander 1994). Gagliese and Katz (2003) suggest that pain scales may be unreliable with older people and that the analgesic effect of opioids is increased in older people. Macrae (2008) report that the younger patients are who have had mastectomy, or hernia operations, the more likely they are to develop chronic postoperative pain. In breast surgery patients, this was explained as being owing to younger patients being more likely to have more severe disease, a higher rate of recurrence and a poorer prognosis.

Limitations of study This study uses secondary analysis of previously collected data, which enables swift and economical access to data without further burden on respondents. However, one of the disadvantages of using this approach is that the questions were predetermined and analysis could only be conducted with the variables collected in the original study. An approximation of what constituted a ‘surgical patient’ had to be made by patients’ responses to a question about whether they had undergone an operation or procedure. There is clearly room for some error here. Survey style research relies on patient self-report that may not always be accurate (Kelley et al. 2003, Polit & Beck 2006). Responses may also be influenced by other factors depending on the conduct of the study, for example, the length of time after discharge from hospital when the data were collected or the extent of follow-up of non-responders in the original study. This survey collected data on a global and retrospective view of the pain experience rather than assessing pain experiences at the time of occurrence.

Relevance for clinical practice Effective pain control is important for the provision of humane patient care, for meeting patients’ physical and psychological needs and minimising the risk of postoperative complications. It also facilitates earlier hospital discharge, improves feelings of well-being and enables return to work and social activities. The study findings demonstrate a significant number of patients still reporting SEP, more than 20 years after the Pain After Surgery report highlighted this problem. There remains scope to improve the quality of patient care by implementing evidence-based practice including undertaking regular structured pain assessments, consulting patients, using appropriate pain scores, administering analgesia according to the WHO Pain Ladder, responding to patients

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in pain with systematic assessment and patient examination, evaluating the effects of medication, accurately reporting patient status and making timely referrals to medical staff etc.

Conclusion This study reported the secondary analysis of data on patients’ experiences of their hospital stay in surgical settings by accessing a large data set from a cross-sectional survey of a random sample of inpatients, within a Health Board in Scotland. Patients from surgical settings reported a high prevalence of pain providing evidence that pain management continues to be suboptimal. Over two-thirds reported they had experienced pain during their hospital stay, around a quarter reported they had experienced pain for all or most of the time, and if patients in the latter group reported that pain experienced was usually severe, they were categorised as having SEP, accounting for 12Æ3% (278) of the total sample. Patient demographics in the SEP group indicated they were more likely to be woman, to have an emergency admission, and were of a younger average age than those without SEP. Such findings may offer healthcare staff opportunities to target patients with specific risk factors for SEP. Those in the SEP group were also more likely to report lower levels of satisfaction with pain management by hospital staff, and with the amount of pain medication they had received. These findings should be tested in further large scale studies. Methodologically, this study illustrates the potential feasibility of secondary analysis of large data sets to address research questions formulated after the completion of an initial study. By combining existing variables to construct the new variable of SEP, and by filtering the data for patients who had received an operation or a procedure, the prevalence of SEP reported by patients in surgical settings and their demographic characteristics could be examined. Secondary analysis of existing databases offers a cost-effective option for accessing large data sets for approved research projects.

Acknowledgements This study was supported by a grant from the Development Trust Research Fund of the University of Edinburgh. The authors would also like to acknowledge Dr. Pat Straw (Patient and Public Partnership Network, NHS Lothian) for access to the original data and her continued support for this study. The authors would also like to acknowledge the support of Juliet MacArthur, Lead Nurse Research NHS Lothian. Ó 2012 Blackwell Publishing Ltd Journal of Clinical Nursing, 21, 3361–3371

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Funding

Contributions

This study was supported by a grant from the Development Trust Research Fund of the University of Edinburgh.

Study design: SR, JT; data collection and analysis: SR, JT, MS, DW, LD and manuscript preparation: SR, JT, MC.

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Pain management


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